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Phanuphak N, Seekaew P, Phanuphak P. Optimising treatment in the test-and-treat strategy: what are we waiting for? Lancet HIV 2019; 6:e715-e722. [PMID: 31515166 DOI: 10.1016/s2352-3018(19)30236-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/10/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
To move from science to guidelines, more than a decade was spent debating the clinical benefits, public health benefits, client autonomy, ethical conflicts, and adherence challenges for the HIV test-and-treat strategy. 2 years after WHO recommended antiretroviral therapy (ART) initiation for all, only 66% of countries reported full implementation. Many countries with the highest HIV burden, with increasing new HIV infections and HIV-related deaths, have not yet adopted or fully implemented the strategy. Whether to implement rapid or same-day ART should not follow the same cycle of debate. Now that there is strong evidence and high policy adoption, the test-and-treat strategy must be implemented as efficiently as possible. More research is needed to optimise-not delay-its implementation.
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Affiliation(s)
- Nittaya Phanuphak
- PREVENTION, Thai Red Cross AIDS Research Centre, Pathumwan, Bangkok 10330, Thailand.
| | - Pich Seekaew
- PREVENTION, Thai Red Cross AIDS Research Centre, Pathumwan, Bangkok 10330, Thailand
| | - Praphan Phanuphak
- PREVENTION, Thai Red Cross AIDS Research Centre, Pathumwan, Bangkok 10330, Thailand
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Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness. Sci Rep 2019; 9:12621. [PMID: 31477764 PMCID: PMC6718403 DOI: 10.1038/s41598-019-49109-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/19/2019] [Indexed: 11/26/2022] Open
Abstract
Although many African countries have achieved high levels of HIV diagnosis, funding constraints have necessitated greater focus on more efficient testing approaches. We compared the impact and cost-effectiveness of several potential new testing strategies in South Africa, and assessed the prospects of achieving the UNAIDS target of 95% of HIV-positive adults diagnosed by 2030. We developed a mathematical model to evaluate the potential impact of home-based testing, mobile testing, assisted partner notification, testing in schools and workplaces, and testing of female sex workers (FSWs), men who have sex with men (MSM), family planning clinic attenders and partners of pregnant women. In the absence of new testing strategies, the diagnosed fraction is expected to increase from 90.6% in 2020 to 93.8% by 2030. Home-based testing combined with self-testing would have the greatest impact, increasing the fraction diagnosed to 96.5% by 2030, and would be highly cost-effective compared to currently funded HIV interventions, with a cost per life year saved (LYS) of $394. Testing in FSWs and assisted partner notification would be cost-saving; the cost per LYS would also be low in the case of testing MSM ($20/LYS) and self-testing by partners of pregnant women ($130/LYS).
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Mesic A, Halim N, MacLeod W, Haker C, Mwansa M, Biemba G. Facilitators and Barriers to Adherence to Antiretroviral Therapy and Retention in Care Among Adolescents Living with HIV/AIDS in Zambia: A Mixed Methods Study. AIDS Behav 2019; 23:2618-2628. [PMID: 31093820 DOI: 10.1007/s10461-019-02533-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Little is known about the factors that contribute to the losses during stages of the HIV continuum of care (CoC) and specifically during the latter stages of antiretroviral (ART) adherence and retention in HIV care among adolescents living with HIV/AIDS (ALHA) in sub-Saharan Africa. We conducted a mixed-methods study: six focus group discussions with 43 ALHA (age 17-19); in-depth interviews with four (age 18-19): and survey-based interviews with 330 ALHA (age 18-19) to identify, understand, and describe factors contributing to the losses in the latter stages of the CoC among ALHA in Zambia. Through focus group discussions and in-depth interviews, ALHA identified barriers at the intrapersonal level (e.g., poverty; lack of adequate nutrition; fear of stigma), interpersonal level (e.g., stigma; disrespectful treatment by providers), institutional/facility level (e.g., lack of adolescent specific services), and community level (e.g., lack of collaboration among organizations; social norms). In quantitative interviews, we found that 46% (101/220) of ALHA reported missing any clinic appointments in the past three months, and about 19% (41/221) reporting missing one or more doses of ART in the last week. Logistic regressions indicate that walking to the site of appointment and being currently employed were predictive of missed visits. Findings highlight the complexity of the multiple factors that are unique to ALHA in Zambia, which should be addressed to improve adherence to ART and retention in HIV.
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Magaço A, Dovel K, Cataldo F, Nhassengo P, Hoffman R, Nerua L, Tique J, Saide M, Couto A, Mbofana F, Gudo E, Cuco RM, Chicumbe S. 'Good health' as a barrier and facilitator to ART initiation: a qualitative study in the era of test-and-treat in Mozambique. CULTURE, HEALTH & SEXUALITY 2019; 21:1059-1073. [PMID: 30636559 DOI: 10.1080/13691058.2018.1535091] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/09/2018] [Indexed: 06/09/2023]
Abstract
HIV test-and-treat programmes are being implemented throughout sub-Saharan Africa, enrolling HIV-positive clients into antiretroviral treatment (ART) immediately after diagnosis, regardless of clinical stage or CD4 count. This study conducted in Mozambique examined what influenced clients who tested HIV-positive in the context of test-and-treat to make ART initiation decisions. Eighty in-depth interviews with HIV-positive clients and nine focus group discussions with health care workers were completed across 10 health facilities. 'Good health' acted simultaneously as a barrier and facilitator; clients in good health often found a positive HIV diagnosis hard to cope with since HIV was traditionally associated with ill health. Concerns about ART side effects, fear of inadvertent HIV status disclosure and discrimination, limited privacy at health facilities and long waiting times were also barriers to initiation. In contrast, being in good health also acted as a motivator to start treatment so as to remain healthy, maintain responsibilities such as work and caring for dependents and avoid unwanted disclosure. Study findings offer an in-depth understanding of the complex dynamics between individual perceptions of 'being healthy' and its influence on ART initiation within the context of test-and-treat programme implementation.
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Affiliation(s)
- Amílcar Magaço
- a Research Department , National Institute of Health , Maputo , Mozambique
| | - Kathryn Dovel
- b Division of Infectious Diseases, Department of Medicine , University of California , Los Angeles , CA , USA
- c Research Department , Partners in Hope , Lilongwe , Malawi
| | - Fabian Cataldo
- d Institute for Global Health and Development , Queen Margaret University , Edinburgh , UK
| | - Pedroso Nhassengo
- a Research Department , National Institute of Health , Maputo , Mozambique
| | - Risa Hoffman
- b Division of Infectious Diseases, Department of Medicine , University of California , Los Angeles , CA , USA
| | - Lucas Nerua
- a Research Department , National Institute of Health , Maputo , Mozambique
| | - José Tique
- e National STI, HIV/AIDS Control Program , Maputo , Mozambique
| | - Mohomed Saide
- a Research Department , National Institute of Health , Maputo , Mozambique
| | - Aleny Couto
- e National STI, HIV/AIDS Control Program , Maputo , Mozambique
| | | | - Eduardo Gudo
- a Research Department , National Institute of Health , Maputo , Mozambique
| | | | - Sérgio Chicumbe
- a Research Department , National Institute of Health , Maputo , Mozambique
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Amstutz A, Lejone TI, Khesa L, Muhairwe J, Nsakala BL, Tlali K, Bresser M, Tediosi F, Kopo M, Kao M, Klimkait T, Battegay M, Glass TR, Labhardt ND. VIBRA trial - Effect of village-based refill of ART following home-based same-day ART initiation vs clinic-based ART refill on viral suppression among individuals living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho. Trials 2019; 20:522. [PMID: 31439004 PMCID: PMC6704675 DOI: 10.1186/s13063-019-3510-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 06/10/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND There is a need for evaluating community-based antiretroviral therapy (ART) delivery models to improve overall performance of HIV programs, specifically in populations that may have difficulties to access continuous care. This cluster-randomized clinical trial aims to evaluate the effectiveness of a multicomponent differentiated ART delivery model (VIBRA model) after home-based same-day ART initiation in remote villages in Lesotho, southern Africa. METHODS/DESIGN The VIBRA trial (VIllage-Based Refill of ART) is a cluster-randomized parallel-group superiority clinical trial conducted in two districts in Lesotho, southern Africa. Clusters (i.e., villages) are randomly assigned to either the VIBRA model or standard care. The clusters are stratified by district, village size, and village access to the nearest health facility. Eligible individuals (HIV-positive, aged 10 years or older, and not taking ART) identified during community-based HIV testing campaigns are offered same-day home-based ART initiation. The intervention clusters offer a differentiated ART delivery package with two features: (1) drug refills and follow-ups by trained and supervised village health workers (VHWs) and (2) the option of receiving individually tailored adherence reminders and notifications of viral load results via SMS. The control clusters will continue to receive standard care, i.e., collecting ART refills from a clinic and no SMS notifications. The primary endpoint is viral suppression 12 months after enrolment. Secondary endpoints include linkage to and engagement in care. Furthermore, safety and cost-effectiveness analyses plus qualitative research are planned. The minimum target sample size is 262 participants. The statistical analyses will follow the CONSORT guidelines. The VIBRA trial is linked to another trial, the HOSENG (HOme-based SElf-testiNG) trial, both of which are within the GET ON (GETing tOwards Ninety) research project. DISCUSSION The VIBRA trial is among the first to evaluate the delivery of ART by VHWs immediately after ART initiation. It assesses the entire HIV care cascade from testing to viral suppression. As most countries in sub-Saharan Africa have cadres like the VHW program in Lesotho, this model-if shown to be effective-has the potential to be scaled up. The system impact evaluation will provide valuable cost estimations, and the qualitative research will suggest how the model could be further modified to optimize its impact. TRIAL REGISTRATION Clinicaltrials.gov, NCT03630549 . Registered on 15 August 2018.
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Affiliation(s)
- Alain Amstutz
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
| | | | - Lefu Khesa
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Josephine Muhairwe
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | | | - Katleho Tlali
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
- Butha-Buthe Government Hospital, Butha-Buthe, Lesotho
| | - Moniek Bresser
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Fabrizio Tediosi
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Mathebe Kopo
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Mpho Kao
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Thomas Klimkait
- University of Basel, 4051 Basel, Switzerland
- Molecular Virology, Department of Biomedicine, University of Basel, 4051 Basel, Switzerland
| | - Manuel Battegay
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
| | - Tracy Renée Glass
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Clinical Research Unit, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- University of Basel, 4051 Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
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106
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Kelly N, Maokola W, Mudasiru O, McCoy SI. Interventions to Improve Linkage to HIV Care in the Era of "Treat All" in Sub-Saharan Africa: a Systematic Review. Curr HIV/AIDS Rep 2019; 16:292-303. [PMID: 31201613 PMCID: PMC10655251 DOI: 10.1007/s11904-019-00451-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF THE REVIEW In 2015, antiretroviral therapy (ART) was recommended for all people living with HIV (PLHIV) regardless of CD4 count ("Treat All"). To better understand how to improve linkage to care under these new guidelines, we conducted a systematic review of studies evaluating linkage interventions in Sub-Saharan Africa under Treat All. RECENT FINDINGS We identified 14 eligible articles and qualitatively analyzed the effectiveness of the interventions. Increases in linkage were reported by supply-side and counseling interventions. Mobile testing and economic incentives did not increase linkage. Given the lag time between adoption and implementation, only two of the studies were conducted in a Treat All setting. None of the interventions specifically focused on re-linking PLHIV who had disengaged from care. Future studies must design interventions that target not only newly diagnosed or treatment naïve PLHIV, but should explicitly focus on PLHIV who have disengaged from care.
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Affiliation(s)
- Nicole Kelly
- University of California, 2121 Berkeley Way, MC 7360, Berkeley, CA, 94720, USA.
| | - Werner Maokola
- University of California, 2121 Berkeley Way, MC 7360, Berkeley, CA, 94720, USA
- Community Development, Gender, Elderly, and Children, Ministry of Health, Dar es Salaam, Tanzania
| | - Omobola Mudasiru
- University of California, 2121 Berkeley Way, MC 7360, Berkeley, CA, 94720, USA
| | - Sandra I McCoy
- University of California, 2121 Berkeley Way, MC 7360, Berkeley, CA, 94720, USA
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Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa. PLoS Med 2019; 16:e1002874. [PMID: 31335865 PMCID: PMC6650049 DOI: 10.1371/journal.pmed.1002874] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/28/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues. METHODS AND FINDINGS We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces (Gauteng, North West, Limpopo, and KwaZulu Natal). We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation (Jan 1, 2015) for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30-49 years, and median CD4 count at ART initiation was 268 cells/μL. AC patients had higher 1-year retention (89.5% versus 81.6%, aRD: 8.3%; 95% CI: 1.1% to 15.6%) and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; 95% CI: -6.9% to 14.4%). Retention associations were apparently stronger for men than women (men RD: 13.1%, 95% CI: 0.3% to 23.5%; women RD: 6.0%, 95% CI: -0.9% to 12.9%). For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30-49 years, and median CD4 count at ART initiation was 270 cells/μL. DMD patients had apparently lower retention (81.5% versus 87.2%, aRD: -5.9%; 95% CI: -12.5% to 0.8%) and comparable viral suppression versus standard of care (77.2% versus 74.3%, aRD: -1.0%; 95% CI: -12.2% to 10.1%), though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men (RD: 11.1%; 95% CI: -3.4% to 25.5%). The main study limitations were missing data and lack of randomization in the DMD analysis. CONCLUSIONS In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated. CLINICAL TRIAL REGISTRATION NCT02536768.
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Affiliation(s)
- Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N. Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David Wilson
- The World Bank Group, Washington DC, United States of America
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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Mateo-Urdiales A, Johnson S, Smith R, Nachega JB, Eshun-Wilson I. Rapid initiation of antiretroviral therapy for people living with HIV. Cochrane Database Syst Rev 2019; 6:CD012962. [PMID: 31206168 PMCID: PMC6575156 DOI: 10.1002/14651858.cd012962.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite antiretroviral therapy (ART) being widely available, HIV continues to cause substantial illness and premature death in low-and-middle-income countries. High rates of loss to follow-up after HIV diagnosis can delay people starting ART. Starting ART within seven days of HIV diagnosis (rapid ART initiation) could reduce loss to follow-up, improve virological suppression rates, and reduce mortality. OBJECTIVES To assess the effects of interventions for rapid initiation of ART (defined as offering ART within seven days of HIV diagnosis) on treatment outcomes and mortality in people living with HIV. We also aimed to describe the characteristics of rapid ART interventions used in the included studies. SEARCH METHODS We searched CENTRAL, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, and four other databases up to 14 August 2018. There was no restriction on date, language, or publication status. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and websites for unpublished literature, including conference abstracts. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared rapid ART versus standard care in people living with HIV. Children, adults, and adolescents from any setting were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of the studies identified in the search, assessed the risk of bias and extracted data. The primary outcomes were mortality and virological suppression at 12 months. We have presented all outcomes using risk ratios (RR), with 95% confidence intervals (CIs). Where appropriate, we pooled the results in meta-analysis. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included seven studies with 18,011 participants in the review. All studies were carried out in low- and middle-income countries in adults aged 18 years old or older. Only one study included pregnant women.In all the studies, the rapid ART intervention was offered as part of a package that included several cointerventions targeting individuals, health workers and health system processes delivered alongside rapid ART that aimed to facilitate uptake and adherence to ART.Comparing rapid ART with standard initiation probably results in greater viral suppression at 12 months (RR 1.18, 95% CI 1.10 to 1.27; 2719 participants, 4 studies; moderate-certainty evidence) and better ART uptake at 12 months (RR 1.09, 95% CI 1.06 to 1.12; 3713 participants, 4 studies; moderate-certainty evidence), and may improve retention in care at 12 months (RR 1.22, 95% CI 1.11 to 1.35; 5001 participants, 6 studies; low-certainty evidence). Rapid ART initiation was associated with a lower mortality estimate, however the CIs included no effect when compared to standard of care (RR 0.72, 95% CI 0.51 to 1.01; 5451 participants, 7 studies; very low-certainty evidence). It is uncertain whether rapid ART has an effect on modification of ART treatment regimens as data are lacking (RR 7.89, 95% CI 0.76 to 81.74; 977 participants, 2 studies; very low-certainty evidence). There was insufficient evidence to draw conclusions on the occurrence of adverse events. AUTHORS' CONCLUSIONS RCTs that include initiation of ART within one week of diagnosis appear to improve outcomes across the HIV treatment cascade in low- and middle-income settings. The studies demonstrating these effects delivered rapid ART combined with several setting-specific cointerventions. This highlights the need for pragmatic research to identify feasible packages that assure the effects seen in the trials when delivered through complex health systems.
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Affiliation(s)
- Alberto Mateo-Urdiales
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, L3 5QA
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Stopard IJ, McGillen JB, Hauck K, Hallett TB. The influence of constraints on the efficient allocation of resources for HIV prevention. AIDS 2019; 33:1241-1246. [PMID: 30649065 PMCID: PMC6511422 DOI: 10.1097/qad.0000000000002158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To investigate how 'real-world' constraints on the allocative and technical efficiency of HIV prevention programmes affect resource allocation and the number of infections averted. DESIGN Epidemiological modelling and economic analyses in Benin, South Africa and Tanzania. METHODS We simulated different HIV prevention programmes, and first determined the most efficient allocation of resources, in which the HIV prevention budget is shared among specific interventions, risk-groups and provinces to maximize the number of infections averted. We then identified the efficient allocation of resources and achievable impact given the following constraints to allocative efficiency: earmarking [provinces with budgets fund pre-exposure prophylaxis (PrEP) for low-risk women first], meeting targets [provinces with budgets fund universal test-and-treat (UTT) first] and minimizing changes in the geographical distribution of funds. We modelled technical inefficiencies as a reduction in the coverage of PrEP or UTT, which were factored into the resource allocation process or took effect following the allocation. Each scenario was investigated over a range of budgets, such that the impact reaches its maximum. RESULTS The 'earmarking', 'meeting targets' and 'minimizing change' constraints reduce the potential impact of HIV prevention programmes, but at the higher budgets these constraints have little to no effect (approximately 35 billion US$ in Tanzania). Over-estimating technical efficiency can result in a loss of impact compared to what would be possible if technical efficiencies were known accurately. CONCLUSION Failing to account for constraints on allocative and technical efficiency can result in the overestimation of the health gains possible, and for technical inefficiencies the allocation of an inefficient strategy.
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Affiliation(s)
- Isaac J Stopard
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Mee P, Rice B, Lemsalu L, Hargreaves J, Sambu V, Harklerode R, Todd J, Somi G. Changes in patterns of retention in HIV care and antiretroviral treatment in Tanzania between 2008 and 2016: an analysis of routinely collected national programme data. J Glob Health 2019; 9:010424. [PMID: 30992984 PMCID: PMC6445500 DOI: 10.7189/jogh.09.010424] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tanzania is a high HIV burden country in Sub-Saharan Africa with 1.5 million people infected. Unless monitored and responded to, low levels of retention in care may lead to poor HIV associated clinical outcomes and an increased likelihood of onward viral transmission. Using routine data, we assessed changes in retention in care and on treatment for HIV over time in Tanzanian facilities, using the national care and treatment programme (CTC) database. METHODS Data were extracted from the CTC database and analysed using two approaches: a series of cross-sectional analyses for each calendar year between 2008 and 2016 to assess the changing characteristics of the population in care and on treatment, and, a longitudinal analysis using survival analysis methods for a series of cohorts representing i) all engaging in care and ii) all initiating treatment in each calendar year from 2008 to 2015. Multivariate analyses were carried out to explore the independent effect of calendar year when controlling for other factors. RESULTS The total number of individuals enrolled in care increased from 160 268 in 2008 to 548 296 in 2016. The percentage of the in-care population enrolled for more than 3 years increased from 9.9% in 2008 to 54.5% in 2016. The overall rates of retention in care were 80.9%, 57.3% and 45.4% at 12, 24 and 36 months respectively. The rates of retention on antiretroviral therapy (ART) ART at 12, 24 and 36 months after treatment-initiation were 83.9%, 64.0% and 53.5%. There were small but statistically significant differences in the retention rates between cohorts and evidence for a significant decrease in the rates of retention in the most recent years analysed. CONCLUSIONS Data from Tanzania show that while the number of People Living with HIV (PLHIV) who were in care and monitored through the routine data system increased over time, the retention rates in care and treatment remained relatively stable. These rates were similar to other regional estimates. Systematic reviews of tracing studies indicate that mortality among those lost to follow up has decreased over time, partly underpinned by an increase in the numbers transferring between clinics. True retention rates may therefore be higher than we report here, and this underpins the need for data systems that can track patients between clinics.
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Affiliation(s)
- Paul Mee
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Brian Rice
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Liis Lemsalu
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
- Department of Drug and Infectious Diseases Epidemiology, National Institute for Health Development, Tallinn, Estonia
| | - James Hargreaves
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Veryeh Sambu
- Strategic Information Unit, National AIDS Control Programme, Dodoma Tanzania
| | - Richelle Harklerode
- University of California San Francisco, Global Health Sciences, San Francisco, California, USA
| | - Jim Todd
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Geoffrey Somi
- Strategic Information Unit, National AIDS Control Programme, Dodoma Tanzania
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Abstract
Kenya has been home to one of the most severe HIV/AIDS epidemics in Sub-Saharan Africa. This persistent epidemic requires interventions tailored to affected populations, particularly men who have sex with men (MSM). Given the resource constraints of many clinics and ecological challenges of Kenya, such as the illegality of sex among MSM, interventions to address HIV must strategically engage this population. This quasi-experimental pilot study of N = 497 sought to explore differences in discovering previously unknown HIV-positive MSM in Nairobi, Kenya. The study used four clinical sites to compare a social and sexual network index testing (SSNIT) strategy compared to traditional HIV screening. Clinics using the SSNIT strategy had significantly higher incidence rates of HIV diagnoses than control clinics (IRR = 3.98, p < 0.001). This study found that building upon the social and sexual networks of MSM may be one promising strategy while discovering critical cases of HIV.
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112
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Gergen J, Falcao J, Rajkotia Y. Stunted scale-up of a performance-based financing program on HIV and maternal-child health services in Mozambique - a policy analysis. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2019; 17:353-361. [PMID: 30560732 DOI: 10.2989/16085906.2018.1544574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE A performance-based financing (PBF) program was implemented for services for HIV, prevention of mother-to-child transmission (PMTCT) and maternal/child health (MCH) in two provinces of Mozambique. This study investigates the determinants of policy scale-up to help accelerate the expansion of PBF in Mozambique and globally from pilot projects to national policies. METHODS A retrospective policy programme analysis was carried out using in-depth key informant interviews. A total of 24 interviews were conducted with stakeholders from donor agencies, the implementing NGO, district and provincial health offices, and the Ministry of Health. RESULTS Stakeholders reported that the scale-up process of PBF was influenced by three key determinants: political power, financial sustainability, and available capacity and evidence. In Mozambique, PBF scaled-up provincially but not nationally due to these determinants. The adoption of PBF in Mozambique involved a restricted range of policy actors at the central level and was strongly driven by the donor and a PBF champion. Provincial scale-up was fostered by political support and increasing capacity over time. CONCLUSION There was a generalised ambivalence and lack of incentive to scale-up PBF from the implementing NGO. Coupled with the lack of evidence of a positive effect, and of cost-effectiveness in comparison with other models to improve health service delivery and health system strengthening, it is difficult to argue for the need to scale up the PBF programme studied. Care needs to be taken to base the adoption of health policies, including PBF, on a situational analysis and on evidence of intervention effectiveness, cost-benefits and contextual fit.
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113
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Haas AD, Zaniewski E, Anderegg N, Ford N, Fox MP, Vinikoor M, Dabis F, Nash D, Sinayobye JD, Niyongabo T, Tanon A, Poda A, Adedimeji AA, Edmonds A, Davies MA, Egger M. Retention and mortality on antiretroviral therapy in sub-Saharan Africa: collaborative analyses of HIV treatment programmes. J Int AIDS Soc 2019; 21. [PMID: 29479867 PMCID: PMC5897849 DOI: 10.1002/jia2.25084] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/29/2018] [Indexed: 01/17/2023] Open
Abstract
Introduction By 2020, 90% of all people diagnosed with HIV should receive long‐term combination antiretroviral therapy (ART). In sub‐Saharan Africa, this target is threatened by loss to follow‐up in ART programmes. The proportion of people retained on ART long‐term cannot be easily determined, because individuals classified as lost to follow‐up, may have self‐transferred to another HIV treatment programme, or may have died. We describe retention on ART in sub‐Saharan Africa, first based on observed data as recorded in the clinic databases, and second adjusted for undocumented deaths and self‐transfers. Methods We analysed data from HIV‐infected adults and children initiating ART between 2009 and 2014 at a sub‐Saharan African HIV treatment programme participating in the International epidemiology Databases to Evaluate AIDS (IeDEA). We used the Kaplan–Meier method to calculate the cumulative incidence of retention on ART and the Aalen–Johansen method to calculate the cumulative incidences of death, loss to follow‐up, and stopping ART. We used inverse probability weighting to adjust clinic data for undocumented mortality and self‐transfer, based on estimates from a recent systematic review and meta‐analysis. Results We included 505,634 patients: 12,848 (2.5%) from Central Africa, 109,233 (21.6%) from East Africa, 347,343 (68.7%) from Southern Africa and 36,210 (7.2%) from West Africa. In crude analyses of observed clinic data, 52.1% of patients were retained on ART, 41.8% were lost to follow‐up and 6.0% had died 5 years after ART initiation. After accounting for undocumented deaths and self‐transfers, we estimated that 66.6% of patients were retained on ART, 18.8% had stopped ART and 14.7% had died at 5 years. Conclusions Improving long‐term retention on ART will be crucial to attaining the 90% on ART target. Naïve analyses of HIV cohort studies, which do not account for undocumented mortality and self‐transfer of patients, may severely underestimate both mortality and retention on ART.
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Affiliation(s)
- Andreas D Haas
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Elizabeth Zaniewski
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nanina Anderegg
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nathan Ford
- World Health Organisation, Geneva, Switzerland
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Michael Vinikoor
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,School of Medicine, University of Zambia, Lusaka, Zambia
| | - François Dabis
- ISPED, Centre Inserm U1219-Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
| | - Denis Nash
- Department of Epidemiology and Biostatistics, City University of New York, School of Public Health, New York, NY, USA.,Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA
| | | | - Thêodore Niyongabo
- Centre National de Reference en Matiere de VIH/SIDA (CNR), Bujumbura, Burundi
| | - Aristophane Tanon
- Service de Maladies Infectieuses et Tropicales (SMIT), CHU de Treichville, Abidjan, Cote d'Ivoire
| | - Armel Poda
- Institut Supérieur des Sciences de la santé, Université Polytechnique de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - Adebola A Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Andrew Edmonds
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Matthias Egger
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.,Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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114
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Bhatta DN, Adhikari R, Karki S, Koirala AK, Wasti SP. Life expectancy and disparities in survival among HIV-infected people receiving antiretroviral therapy: an observational cohort study in Kathmandu, Nepal. BMJ Glob Health 2019; 4:e001319. [PMID: 31179033 PMCID: PMC6529021 DOI: 10.1136/bmjgh-2018-001319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 04/01/2019] [Accepted: 04/20/2019] [Indexed: 11/08/2022] Open
Abstract
Introduction The advent of antiretroviral therapy (ART) has dramatically slowed down the progression of HIV. This study assesses the disparities in survival, life expectancy and determinants of survival among HIV-infected people receiving ART. Methods Using data from one of Nepal’s largest population-based retrospective cohort studies (in Kathmandu, Nepal), we followed a total of 3191 HIV-infected people aged 15 years and older who received ART over the period of 2004–2015. We created abridged life tables with age-specific survival rates and life expectancy, stratified by sex, ethnicity, CD4 cell counts and the WHO-classified clinical stage at initiation of ART. Results HIV-infected people who initiated ART with a CD4 cell count of >200 cells/cm3 at 15 years had 27.4 (22.3 to 32.6) years of additional life. People at WHO-classified clinical stage I and 15 years of age who initiated ART had 23.1 (16.6 to 29.7) years of additional life. Life expectancy increased alongside the CD4 cell count and decreased as clinical stages progressed upward. The study cohort contributed 8484.8 person years, with an overall survival rate of 3.3 per 100 person years (95% CI 3.0 to 3.7). Conclusions There are disparities in survival among HIV-infected people in Nepal. The survival payback of ART is proven; however, late diagnosis or the health system as a whole will affect the control and treatment of the illness. This study offers evidence of the benefits of enrolling early in care in general and ART in particular.
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Affiliation(s)
- Dharma N Bhatta
- Department of Community Medicine and Public Health, Tribhuvan University, Peoples Dental College, Kathmandu, Nepal
| | - Ruchi Adhikari
- Department of Dentistry, Nepal Medical College Teaching Hospital, Kathmandu, Nepal
| | - Sushil Karki
- Department of Microbiology, Pokhara University, Nobel College, Kathmandu, Nepal
| | - Arun K Koirala
- Department of Public Health, Pokhara University, Lekhnath, Nepal
| | - Sharada P Wasti
- Department of Maternal Health, Institute for Reproductive Health, Kathmandu, Nepal
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Venter WDF, Fischer A, Lalla-Edward ST, Coleman J, Lau Chan V, Shubber Z, Phatsoane M, Gorgens M, Stewart-Isherwood L, Carmona S, Fraser-Hurt N. Improving Linkage to and Retention in Care in Newly Diagnosed HIV-Positive Patients Using Smartphones in South Africa: Randomized Controlled Trial. JMIR Mhealth Uhealth 2019; 7:e12652. [PMID: 30938681 PMCID: PMC6465976 DOI: 10.2196/12652] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/21/2018] [Accepted: 01/03/2019] [Indexed: 12/24/2022] Open
Abstract
Background South Africa provides free antiretroviral therapy for almost 5 million people living with HIV, but only 71% of the eligible people are on treatment, representing a shortfall in the care cascade, especially among men and youth. Many developing countries have expanded access to smartphones; success in health apps raises the possibility of improving this cascade. Objective SmartLink is a health app for Android smartphones providing HIV-related laboratory results, information, support, and appointment reminders to engage and link patients to care. This study aimed to evaluate the ability of SmartLink to improve linkage to care for HIV-positive smartphone owners. Methods This study was a multisite randomized controlled trial in Johannesburg. The intervention arm received the app (along with referral to a treatment site) and the control arm received the standard of care (referral alone). Linkage to care was confirmed by an HIV-related blood test reported on the National Health Laboratory Service database between 2 weeks and 8 months after initiation. Results A total of 345 participants were recruited into the study; 64.9% (224/345) of the participants were female and 44.1% (152/345) were aged less than 30 years. In addition, 46.7% (161/345) were employed full time, 95.9% (331/345) had at least secondary school education, and 35.9% (124/345) were from Zimbabwe. Linkage to care between 2 weeks and 8 months was 48.6% (88/181) in the intervention arm versus 45.1% (74/164) in the control (P=.52) and increased to 64.1% (116/181) and 61.0% (100/164) (P=.55), respectively, after the initial 8-month period. Moreover, youth aged 18 to 30-years showed a statistically significant 20% increase in linkage to care for the intervention group. Conclusions Youth aged less than 30 years have been historically difficult to reach with traditional interventions, and the SmartLink app provides a proof of concept that this population reacts to mobile health interventions that engage patients in HIV care. Trial Registration ClinicalTrials.gov NCT02756949; https://clinicaltrials.gov/ct2/show/NCT02756949 (Archived by WebCite at http://www.webcitation.org/6z1GTJCNW)
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Affiliation(s)
| | - Alex Fischer
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | | | - Jesse Coleman
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Vincent Lau Chan
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Zara Shubber
- World Bank, World Bank Group, Washington, DC, United States
| | - Mothepane Phatsoane
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | | | | | - Sergio Carmona
- National Health Laboratory Service, Johannesburg, South Africa
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116
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Ayieko J, Petersen ML, Charlebois ED, Brown LB, Clark TD, Kwarisiima D, Kamya MR, Cohen CR, Bukusi EA, Havlir DV, Van Rie A. A Patient-Centered Multicomponent Strategy for Accelerated Linkage to Care Following Community-Wide HIV Testing in Rural Uganda and Kenya. J Acquir Immune Defic Syndr 2019; 80:414-422. [PMID: 30807481 PMCID: PMC6410970 DOI: 10.1097/qai.0000000000001939] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/26/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION As countries move toward universal HIV treatment, many individuals fail to link to care after diagnosis of HIV. Efficient and effective linkage strategies are needed. METHODS We implemented a patient-centered, multicomponent linkage strategy in the SEARCH "test-and-treat" trial (NCT 01864603) in Kenya and Uganda. After population-based, community-wide HIV testing, eligible participants were (1) introduced to clinic staff after testing, (2) provided a telephone "hot-line" for enquiries, (3) provided an appointment reminder phone call, (4) given transport reimbursement on linkage, and (5) tracked if linkage appointment was missed. We estimated the proportion linked to care within 1 year and evaluated factors associated with linkage at 7, 30, and 365 days after diagnosis. RESULTS Among 71,308 adults tested, 6811 (9.6%) were HIV-infected; of these, 4760 (69.9%) were already in HIV care, and 30.1% were not. Among 2051 not in care, 58% were female, median age was 32 (interquartile range 26-40) years, and median CD4 count was 493 (interquartile range 331-683) cells/µL. Half (49.7%) linked within 1 week, and 73.4% linked within 1 year. Individuals who were younger [15-34 vs. >35 years, adjusted Risk Ratio (aRR) 0.83, 95% confidence interval (CI): 0.74 to 0.94], tested at home vs. community campaign (aRR = 0.87, 95% CI: 0.81 to 0.94), had a high HIV-risk vs. low-risk occupation (aRR = 0.81, 95% CI: 0.75 to 0.88), and were wealthier (aRR 0.90, 95% CI: 0.83 to 0.97) were less likely to link. Linkage did not differ by marital status, stable residence, level of education, or having a phone contact. CONCLUSIONS Using a multicomponent linkage strategy, high proportions of people living with HIV but not in care linked rapidly after HIV testing.
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Affiliation(s)
- James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L. Petersen
- Department of Biostatistics, School of Public Health, University of California, Berkeley, CA
| | | | | | - Tamara D. Clark
- School of Medicine, University of California, San Francisco, CA
| | - Dalsone Kwarisiima
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses R. Kamya
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Craig R. Cohen
- School of Medicine, University of California, San Francisco, CA
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Diane V. Havlir
- School of Medicine, University of California, San Francisco, CA
| | - Annelies Van Rie
- Faculty of Medicine and Public Health, University of Antwerp, Antwerp, Belgium
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117
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Seeley J, Bond V, Yang B, Floyd S, MacLeod D, Viljoen L, Phiri M, Simuyaba M, Hoddinott G, Shanaube K, Bwalya C, de Villiers L, Jennings K, Mwanza M, Schaap A, Dunbar R, Sabapathy K, Ayles H, Bock P, Hayes R, Fidler S. Understanding the Time Needed to Link to Care and Start ART in Seven HPTN 071 (PopART) Study Communities in Zambia and South Africa. AIDS Behav 2019; 23:929-946. [PMID: 30415432 PMCID: PMC6458981 DOI: 10.1007/s10461-018-2335-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To achieve UNAIDS 90:90:90 targets at population-level, knowledge of HIV status must be followed by timely linkage to care, initiation and maintenance of antiretroviral therapy (ART) for all people living with HIV (PLHIV). Interpreting quantitative patterns using qualitative data, we investigate time taken to link to care and initiate ART amongst individuals aware of their HIV-status in high HIV-prevalence urban communities in the HPTN 071 (PopART) study, a community-randomised trial of a combination HIV prevention package, including universal testing and treatment, in 21 communities in Zambia and South Africa. Data are drawn from the seven intervention communities where immediate ART irrespective if CD4 count was offered from the trial-start in 2014. Median time from HIV-diagnosis to ART initiation reduced after 2 years of delivering the intervention from 10 to 6 months in both countries but varied by gender and community of residence. Social and health system realities impact decisions made by PLHIV about ART initiation.
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Affiliation(s)
- Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Virginia Bond
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Blia Yang
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | - David MacLeod
- London School of Hygiene and Tropical Medicine, London, UK
| | - Lario Viljoen
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Mwelwa Phiri
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Melvin Simuyaba
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Kwame Shanaube
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Chiti Bwalya
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Laing de Villiers
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Karen Jennings
- City of Cape Town Health Directorate, Cape Town, South Africa
| | - Margaret Mwanza
- Zambia Prevention Care and Treatment partnership (ZPCT), Lusaka, Zambia
| | - Ab Schaap
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Rory Dunbar
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | | | - Helen Ayles
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Peter Bock
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Medicine, Imperial College, London, UK
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Vesga JF, Hallett TB, Reid MJA, Sachdeva KS, Rao R, Khaparde S, Dave P, Rade K, Kamene M, Omesa E, Masini E, Omale N, Onyango E, Owiti P, Karanja M, Kiplimo R, Alexandru S, Vilc V, Crudu V, Bivol S, Celan C, Arinaminpathy N. Assessing tuberculosis control priorities in high-burden settings: a modelling approach. LANCET GLOBAL HEALTH 2019; 7:e585-e595. [PMID: 30904521 DOI: 10.1016/s2214-109x(19)30037-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/22/2018] [Accepted: 01/11/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND In the context of WHO's End TB strategy, there is a need to focus future control efforts on those interventions and innovations that would be most effective in accelerating declines in tuberculosis burden. Using a modelling approach to link the tuberculosis care cascade to transmission, we aimed to identify which improvements in the cascade would yield the greatest effect on incidence and mortality. METHODS We engaged with national tuberculosis programmes in three country settings (India, Kenya, and Moldova) as illustrative examples of settings with a large private sector (India), a high HIV burden (Kenya), and a high burden of multidrug resistance (Moldova). We collated WHO country burden estimates, routine surveillance data, and tuberculosis prevalence surveys from 2011 (for India) and 2016 (for Kenya). Linking the tuberculosis care cascade to tuberculosis transmission using a mathematical model with Bayesian melding in each setting, we examined which cascade shortfalls would have the greatest effect on incidence and mortality, and how the cascade could be used to monitor future control efforts. FINDINGS Modelling suggests that combined measures to strengthen the care cascade could reduce cumulative tuberculosis incidence by 38% (95% Bayesian credible intervals 27-43) in India, 31% (25-41) in Kenya, and 27% (17-41) in Moldova between 2018 and 2035. For both incidence and mortality, modelling suggests that the most important cascade losses are the proportion of patients visiting the private health-care sector in India, missed diagnosis in health-care settings in Kenya, and drug sensitivity testing in Moldova. In all settings, the most influential delay is the interval before a patient's first presentation for care. In future interventions, the proportion of individuals with tuberculosis who are on high-quality treatment could offer a more robust monitoring tool than routine notifications of tuberculosis. INTERPRETATION Linked to transmission, the care cascade can be valuable, not only for improving patient outcomes but also in identifying and monitoring programmatic priorities to reduce tuberculosis incidence and mortality. FUNDING US Agency for International Development, Stop TB Partnership, UK Medical Research Council, and Department for International Development.
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Affiliation(s)
- Juan F Vesga
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK.
| | - Timothy B Hallett
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Michael J A Reid
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Raghuram Rao
- Central TB Division, New Delhi, India; Central TB Division, New Delhi, India
| | | | | | - Kiran Rade
- WHO India Country Office, New Delhi, India
| | - Maureen Kamene
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Eunice Omesa
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | | | - Newton Omale
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Elizabeth Onyango
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Philip Owiti
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | | | - Richard Kiplimo
- National Tuberculosis, Leprosy and Lung Disease Programme, Nairobi, Kenya
| | - Sofia Alexandru
- National Tuberculosis Programme, 'Chiril Draganiuc' Institute of Phthisiopneumology, Chisinau, Moldova
| | - Valentina Vilc
- National Tuberculosis Programme, 'Chiril Draganiuc' Institute of Phthisiopneumology, Chisinau, Moldova
| | - Valeriu Crudu
- National Tuberculosis Programme, 'Chiril Draganiuc' Institute of Phthisiopneumology, Chisinau, Moldova
| | - Stela Bivol
- Centre for Health Policies and Studies, Chisinau, Moldova
| | - Cristina Celan
- Centre for Health Policies and Studies, Chisinau, Moldova
| | - Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
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Castelnuovo B, Mubiru F, Nakalema S, Twimukye A, Kiragga A. Describing the retention in care of human immunodeficiency virus-positive young adults who transition from adolescent to adult care. Int Health 2019; 10:318-320. [PMID: 29401288 DOI: 10.1093/inthealth/ihx063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 11/24/2017] [Indexed: 11/13/2022] Open
Abstract
Background There is a high rate of lost to programme (LTP) in human immunodeficiency virus (HIV)-positive young adults transitioning from paediatric/adolescent to adult care. Methods We describe and identify risk factors for LTP in all patients 18-23 y of age at the Infectious Diseases Institute (Kampala, Uganda) from 2010 to 2014. Results A total of 260 of 907 young adults (28.6%) became LTP. Among those on antiretroviral treatment, 39.3% became LTP. We found that the only risk factor associated with LTP was being in World Health Organization stage 3 or 4. Conclusion There is a need for tracing studies to evaluate the true vital status of LTP in this group.
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Affiliation(s)
| | - Frank Mubiru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Shadia Nakalema
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Agnes Kiragga
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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120
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Low DH, Phipps W, Orem J, Casper C, Bender Ignacio RA. Engagement in HIV Care and Access to Cancer Treatment Among Patients With HIV-Associated Malignancies in Uganda. J Glob Oncol 2019; 5:1-8. [PMID: 30763144 PMCID: PMC6426497 DOI: 10.1200/jgo.18.00187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Health system constraints limit access to HIV and cancer treatment programs in sub-Saharan Africa. Limited access and continuity of care affect morbidity and mortality of patients with cancer and HIV. We assessed barriers in the care cascade of comorbid HIV and cancer. PATIENTS AND METHODS Structured interviews were conducted with 100 adult patients with HIV infection and new diagnoses of cancer at the Uganda Cancer Institute. Participants completed follow-up questionnaires after 1 year to assess ongoing engagement with and barriers to care. RESULTS The median time from new-onset cancer symptoms to initiation of cancer care at the Uganda Cancer Institute was 209 days (interquartile range, 113 to 384 days). Persons previously established in HIV care waited less overall to initiate cancer care ( P = .04). Patients established in HIV care experienced shorter times from initial symptoms to seeking of cancer care ( P = .02) and from seeking of care to cancer diagnosis ( P = .048). Barriers to receiving care for HIV and cancer included difficulty traveling to multiple clinics/hospitals (46%), conflicts between HIV and cancer appointments (23%), prohibitive costs (21%), and difficulty adhering to medications (15%). Reporting of any barriers to care was associated with premature discontinuation of cancer treatment ( P = .003). CONCLUSION Patients with HIV-associated malignancies reported multiple barriers to receiving care for both conditions, although knowledge of HIV status and engagement in HIV care before presentation with malignancy reduced subsequent time to the start of cancer treatment. This study provides evidence to support creation and evaluation of integrated HIV and cancer care models.
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Affiliation(s)
- Daniel H. Low
- Swedish Family Medicine Residency at Cherry Hill, Seattle, WA
- University of Washington School of Medicine, Seattle, WA
| | - Warren Phipps
- University of Washington School of Medicine, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jackson Orem
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Uganda Cancer Institute, Kampala, Uganda
| | - Corey Casper
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Infectious Diseases Research Institute, Seattle, WA
| | - Rachel A Bender Ignacio
- University of Washington School of Medicine, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
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Linkage to care of HIV positive clients in a community based HIV counselling and testing programme: A success story of non-governmental organisations in a South African district. PLoS One 2019; 14:e0210826. [PMID: 30668598 PMCID: PMC6342293 DOI: 10.1371/journal.pone.0210826] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/02/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction Although current data projects South Africa potentially meeting the UN target to test 90% of all people living with HIV by 2020, linking them to HIV care remains a big challenge. In an effort to increase linkage to care (LTC) of HIV positive clients an innovative collaborative intervention between two non-governmental organisations was developed and implemented between 2016 and 2017. This paper investigated the outcome of this collaborative intervention. Methods We used a mixed methods approach to assess the outcome of the innovative relationship. This was done by analysing routine programmatic quantitative data on LTC between 2015 and 2017 and qualitatively interviewing five programme managers, four programme implementers and five HIV positive clients on their perceived success/failure factors. Qualitative data were analysed using thematic content analysis while LTC rates were descriptively analysed. Two consultative meetings presented draft findings to programme managers (n = 7) and implementers (n = 10) for feedback, results verification and confirmation. Results In 2015 cumulative LTC rate was 27% and it rose to 85% two years post-intervention in 2017. Six themes emerged as success factors at the health system and structural levels and these include: provision of client escort services, health facility human resource capacity strengthening, inter and intra-organisational teamwork, onsite LTC, facilitated and expedited jumping of queues and shifting administrative tasks to non-clinical staff to protect nurses’ time on ART initiation. These measures in turn ensured increased, affordable and swift ART initiation of clients while strengthening client support. Conclusions We concluded that multi-faceted interventions that target both health system challenges including staff shortages, efficiencies, and extended facility opening times, and structural inadequacies, including client time and resource limitations due to poverty or nature of jobs, can help to increase LTC.
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Opollo VS, Nikuze A, Ben-Farhat J, Anyango E, Humwa F, Oyaro B, Wanjala S, Omwoyo W, Majiwa M, Akelo V, Zeh C, Maman D. Field evaluation of near point of care Cepheid GeneXpert HIV-1 Qual for early infant diagnosis. PLoS One 2018; 13:e0209778. [PMID: 30589900 PMCID: PMC6307732 DOI: 10.1371/journal.pone.0209778] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/11/2018] [Indexed: 11/18/2022] Open
Abstract
Background Access to point-of-care HIV testing shortens turn-around times, time to diagnosis and reduces loss to follow-up hence minimizing barriers to early linkage to care and treatment among HIV infected infants. Currently samples for early infant HIV diagnosis are sent to centralized testing facilities which are few and located only at specific regions in Kenya. However, there are Point of Care (POC) early infant diagnosis [EID] technologies elsewhere such as SAMBA and ALERE-Q that are yet to be evaluated in Kenya despite the urgent need for data to inform policy formulation regarding EID. The Cepheid GeneXpert HIV-1 Qual (GeneXpert) technology for POC EID offers a great opportunity to minimize HIV associated morbidity, mortality and loss to follow-up through decentralization of early infant HIV testing to the clinics. This technology also allows for same-day results thus facilitating prompt linkage to care. Methods We evaluated the GeneXpert HIV Qual EID POC in Homabay County against the standard of care platform, Roche CAP/CTM HIV-1 qualitative PCR, using dried blood spots (DBS). Between February—July 2016, DBS samples were collected from HIV exposed children <18 months of age enrolled in a cross-sectional study. Samples were collected by qualified nurse counselors, and were tested by trained technicians using field based GeneXpert and conventional laboratory based Roche CAP/CTM HIV-1 qualitative PCR. Sensitivity and specificity were determined. Results Overall, 3,814 mother/infant pairs were included in the study, out of which 921 infants were HIV exposed as per the mothers’ HIV status and based on the infant’s HIV rapid test. A total of 969 PCR tests were performed, out of which 30 (3.3%) infants were concordantly positive using both platforms. GeneXpert HIV-1 Qual yielded a sensitivity of 94.1% and specificity of 99.8% with an overall error rate of 0.7%. Conclusion Our findings show that GeneXpert HIV-1 Qual performs well compared to CAP/CTM using DBS samples, suggesting that this technology may be adopted in decentralized laboratories as a near POC device. It may contribute to prompt diagnosis of HIV exposed infants hence enabling early linkage to care, thus advancing further gains in EID.
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Affiliation(s)
- Valarie Sarah Opollo
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
- * E-mail:
| | | | | | - Emily Anyango
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Felix Humwa
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Boaz Oyaro
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | | | | | - Maxwel Majiwa
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Victor Akelo
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Clement Zeh
- U.S. Centers for Disease Control and Prevention, Clinical Research Center, Kisumu, Kenya
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Mitruka K, Bamrotiya M, Agarwal R, Parvez A, Allam RR, Sivalenka S, Deoraj P, Prasad R, Devi U, Keskar P, Acharya S, Kannan P, Ganti R, Shah M, Todmal S, Kumar P, Chava N, Rao A, Tanwar S, Nyendak M, Ellerbrock T, Holtz TH, Gupta R. Implementation of the Treat All Policy Among Persons with HIV Infection Enrolled in Care But Not on Antiretroviral Therapy - India, May 2017-June 2018. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2018; 67:1305-1309. [PMID: 31199351 PMCID: PMC6276382 DOI: 10.15585/mmwr.mm6747a2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Sanga ES, Mukumbang FC, Mushi AK, Olomi W, Lerebo W, Zarowsky C. Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study. AIDS Res Ther 2018; 15:21. [PMID: 30458874 DOI: 10.1186/s12981-018-0209-8n.pag-n.pag] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. METHODS An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). RESULTS More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). CONCLUSIONS Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less "linkage-ready". Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.
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Affiliation(s)
- Erica S Sanga
- NIMR-Mwanza Medical Research Centre (MMRC), Mwanza, Tanzania.
- School of Public Health, University of Western Cape, Cape Town, South Africa.
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania.
| | - Ferdinand C Mukumbang
- School of Public Health, University of Western Cape, Cape Town, South Africa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), Dar-es-Salaam, Tanzania
| | | | - Wondwossen Lerebo
- School of Public Health, University of Western Cape, Cape Town, South Africa
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Christina Zarowsky
- School of Public Health, University of Western Cape, Cape Town, South Africa
- University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal, Montreal, Canada
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Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study. AIDS Res Ther 2018; 15:21. [PMID: 30458874 PMCID: PMC6247671 DOI: 10.1186/s12981-018-0209-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 12/23/2022] Open
Abstract
Background Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. Methods An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). Results More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). Conclusions Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less “linkage-ready”. Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.
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Choko AT, Candfield S, Maheswaran H, Lepine A, Corbett EL, Fielding K. The effect of demand-side financial incentives for increasing linkage into HIV treatment and voluntary medical male circumcision: A systematic review and meta-analysis of randomised controlled trials in low- and middle-income countries. PLoS One 2018; 13:e0207263. [PMID: 30427889 PMCID: PMC6235355 DOI: 10.1371/journal.pone.0207263] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 10/29/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Linkage to HIV treatment is a vital step in the cascade of HIV services and is critical to slowing down HIV transmission in countries with high HIV prevalence. Equally, linkage to voluntary medical male circumcision (VMMC) has been shown to decrease HIV transmission by 60% and increasing numbers of men receiving VMMC has a substantial impact on HIV incidence. However, only 48% of newly diagnosed HIV positive people link to HIV treatment let alone access HIV prevention methods such as VMMC globally. METHODS A systematic review investigating the effect of demand-side financial incentives (DSFIs) on linkage into HIV treatment or VMMC for studies conducted in low- and middle-income countries. We searched the title, abstract and keywords in eight bibliographic databases: MEDLINE, EMBASE, Web of Science, Econlit, Cochrane, SCOPUS, IAS Conference database of abstracts, and CROI Conference database of abstracts. Searches were done in December 2016 with no time restriction. We fitted random effects (RE) models and used forest plots to display risk ratios (RR) and 95% CIs separately for the linkage to VMMC outcome. The RE model was also used to assess heterogeneity for the linkage to HIV treatment outcome. RESULTS Of the 1205 citations identified from searches, 48 full text articles were reviewed culminating in nine articles in the final analysis. Five trials investigated the effect of DSFIs on linkage to HIV treatment while four trials investigated linkage to VMMC. Financial incentives improved linkage to HIV treatment in three of the five trials that investigated this outcome. Significant improvements were observed among postpartum women RR 1.26 (95% CI: 1.08; 1.48), among people who inject drugs RR 1.42 (95% CI: 1.09; 1.96), and among people testing at the clinic RR 1.10 (95% CI: 1.07; 1.14). One of the two trials that did not find significant improvement in linkage to ART was among people testing HIV positive in clinics RR 0.96 (95% CI: 0.81; 1.16) while the other was among new HIV positive individuals identified through a community testing study RR 0.82 (95% CI: 0.56; 1.22). We estimate an average 4-fold increase in the uptake of circumcision among HIV negative uncircumcised men from our fitted RE model with overall RR 4.00 (95% CI: 2.17; 7.37). There was negligible heterogeneity in the estimates from the different studies with I-squared = 0.0%; p = 0.923. CONCLUSIONS Overall, DSFIs appeared to improve linkage for both HIV treatment and VMMC with greater effect for VMMC. Demand-side financial incentives could improve linkage to HIV treatment or VMMC in low- and middle-income countries although uptake by policy makers remains a challenge.
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Affiliation(s)
- Augustine T. Choko
- TB/HIV Theme, Malawi-Liverpool-Wellcome Clinical Research Programme (MLW), Blantyre, Malawi
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Sophie Candfield
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | | | - Aurelia Lepine
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Elizabeth Lucy Corbett
- TB/HIV Theme, Malawi-Liverpool-Wellcome Clinical Research Programme (MLW), Blantyre, Malawi
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Katherine Fielding
- London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
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Carlucci JG, Liu Y, Friedman H, Pelayo BE, Robelin K, Sheldon EK, Clouse K, Vermund SH. Attrition of HIV-exposed infants from early infant diagnosis services in low- and middle-income countries: a systematic review and meta-analysis. J Int AIDS Soc 2018; 21:e25209. [PMID: 30649834 PMCID: PMC6287094 DOI: 10.1002/jia2.25209] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 10/22/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Identification and retention of HIV-exposed infants in early infant diagnosis (EID) services helps to ensure optimal health outcomes. This systematic review and meta-analysis examines the magnitude of attrition from EID services in low- and middle-income countries (LMICs). METHODS We performed a comprehensive database search through April 2016. We included original studies reporting retention/attrition data for HIV-exposed infants in LMICs. Outcomes included loss to follow-up (LTFU), death and overall attrition (LTFU + death) at time points along the continuum of EID services. At least two authors determined study eligibility, performed data extraction and made quality assessments. We used random-effects meta-analytic methods to aggregate effect sizes and perform meta-regression analyses. This study adhered to PRISMA reporting guidelines. RESULTS We identified 3040 unique studies, of which 92 met eligibility criteria and were included in the quantitative synthesis. The included studies represent data from 110,805 HIV-exposed infants, the majority of whom were from Africa (77%). LTFU definitions varied widely, and there was significant variability in outcomes across studies. The bulk of attrition occurred in the first six months of follow-up, with additional losses over time. Overall, 39% of HIV-exposed infants were no longer in care at 18 months. When restricted to non-intervention studies, 43% were not retained at 18 months. CONCLUSIONS These findings underscore the high attrition of HIV-exposed infants from EID services in LMICs and the urgent need for implementation research and resources to improve retention among this vulnerable population.
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Affiliation(s)
- James G Carlucci
- Vanderbilt Institute for Global HealthVanderbilt University Medical CenterNashvilleTNUSA
- Division of Pediatric Infectious DiseasesDepartment of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Yu Liu
- Department of Public Health SciencesSchool of Medicine and DentistryUniversity of RochesterRochesterNYUSA
| | | | | | | | - Emily K Sheldon
- Vanderbilt Institute for Global HealthVanderbilt University Medical CenterNashvilleTNUSA
| | - Kate Clouse
- Vanderbilt Institute for Global HealthVanderbilt University Medical CenterNashvilleTNUSA
| | - Sten H Vermund
- Yale School of Public HealthYale UniversityNew HavenCTUSA
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van der Kop ML, Nagide PI, Thabane L, Gelmon L, Kyomuhangi LB, Abunah B, Ekström AM, Lester RT. Retention in clinic versus retention in care during the first year of HIV care in Nairobi, Kenya: a prospective cohort study. J Int AIDS Soc 2018; 21:e25196. [PMID: 30489698 PMCID: PMC6263088 DOI: 10.1002/jia2.25196] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 09/26/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION When measuring the success of HIV programmes to retain patients in care, few studies distinguish between retention in clinic (individual returns to the same clinic) and retention in care (individual is active in care at initial site or elsewhere). The objectives of this study were to quantify retention in clinic versus retention in care and determine risk factors associated with attrition from care in low-income settings in Nairobi, Kenya. METHODS Between April 2013 and June 2015, adults testing positive for HIV were recruited at two comprehensive care clinics in informal urban settlements. Participants were followed from the time of a positive HIV test for up to 14 months. Participants who did not return to the clinic for their 12-month appointment between 10 and 14 months after their baseline visit were traced by telephone or community outreach to determine whether they were still receiving HIV care. We used generalized linear regression to determine the association between clinical and socio-demographic factors and attrition from care at 12 months. RESULTS Of the 1068 individuals screened for study participation, 775 individuals newly presenting to HIV care were included in this study. Between 10 and 14 months, 486 participants (62.7%, 95% confidence intervals [CI], 59.2% to 66.1%) returned to the clinic for their 12-month appointment (retained in clinic). After telephone tracing and community outreach, an additional 123 of 289 participants were found to be active in care at other HIV clinics (42.6%, 95% CI, 36.8% to 48.5%). Overall, 609 (78.6%, 95% CI, 75.7% to 81.5%) participants were retained in care at any HIV clinic at 12 months. Participants in higher baseline CD4 count categories were more likely to be retained than those whose baseline CD4 count was <200 cells/mm3 . CONCLUSIONS Retention in clinic substantially underestimated retention in care 12 months after presenting to care in this high-prevalence and low-income urban setting. Improved systems to track patients between clinics are required to accurately estimate retention in care in resource-limited settings. Although the proportion of patients retained in care was greater than expected, interventions to improve retention in care are needed to meet global targets to end the AIDS epidemic.
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Affiliation(s)
- Mia L van der Kop
- Department of Public Health Sciences/Global Health (IHCAR)Karolinska InstitutetStockholmSweden
- Department of MedicineUniversity of British ColumbiaVancouverBCCanada
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonONCanada
- Biostatistics UnitSt Joseph's Healthcare—HamiltonHamiltonONCanada
| | - Lawrence Gelmon
- Department of Medical MicrobiologyUniversity of ManitobaWinnipegMBCanada
| | | | | | - Anna Mia Ekström
- Department of Public Health Sciences/Global Health (IHCAR)Karolinska InstitutetStockholmSweden
- Department of Infectious DiseasesKarolinska University HospitalStockholmSweden
| | - Richard T Lester
- Department of MedicineUniversity of British ColumbiaVancouverBCCanada
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Chen J, Ramendra R, Lu H, Routy JP. The early bird gets the worm: benefits and future directions with early antiretroviral therapy initiation in primary HIV infection. Future Virol 2018. [DOI: 10.2217/fvl-2018-0110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Primary HIV infection is defined as the first few weeks after infection where plasma viremia is rapidly increasing. Early diagnosis of primary HIV infection enhances the tendency of behavioral changes in newly infected individuals to prevent secondary HIV transmission. Early antiretroviral therapy (ART) benefits individuals by reducing plasma viral load, gut damage, microbial translocation and subsequent systemic immune activation. Early ART leads to the establishment of low HIV reservoir size that may contribute to HIV eradication research. However, substantial diagnostic and logistical barriers remain as a burden to rapid diagnosis and early treatment initiation. In this review, we critically evaluate the effects of early ART and summarize hurdles that must be addressed to implement rapid treatment initiation for newly infected individuals.
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Affiliation(s)
- Jun Chen
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai 201508, PR China
| | - Rayoun Ramendra
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Department of Microbiology & Immunology, McGill University, Montreal, QC H4A 3J1, Canada
| | - Hongzhou Lu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai 201508, PR China
| | - Jean-Pierre Routy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
- Division of Hematology, Department of Medicine, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
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Mwamba C, Sharma A, Mukamba N, Beres L, Geng E, Holmes CB, Sikazwe I, Topp SM. 'They care rudely!': resourcing and relational health system factors that influence retention in care for people living with HIV in Zambia. BMJ Glob Health 2018; 3:e001007. [PMID: 30483408 PMCID: PMC6231098 DOI: 10.1136/bmjgh-2018-001007] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/08/2018] [Accepted: 08/31/2018] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Despite access to free antiretroviral therapy (ART), many HIV-positive Zambians disengage from HIV care. We sought to understand how Zambian health system 'hardware' (tangible components) and 'software' (work practices and behaviour) influenced decisions to disengage from care among 'lost-to-follow-up' patients traced by a larger study on their current health status. METHODS We purposively selected 12 facilities, from 4 provinces. Indepth interviews were conducted with 69 patients across four categories: engaged in HIV care, disengaged from care, transferred to another facility and next of kin if deceased. We also conducted 24 focus group discussions with 158 lay and professional healthcare workers (HCWs). These data were triangulated against two consecutive days of observation conducted in each facility. We conducted iterative multilevel analysis using inductive and deductive reasoning. RESULTS Health system 'hardware' factors influencing patients' disengagement included inadequate infrastructure to protect privacy; distance to health facilities which costs patients time and money; and chronic understaffing which increased wait times. Health system 'software' factors related to HCWs' work practices and clinical decisions, including delayed opening times, file mismanagement, drug rationing and inflexibility in visit schedules, increased wait times, number of clinic visits, and frustrated access to care. While patients considered HCWs as 'mentors' and trusted sources of information, many also described them as rude, tardy, careless with details and confidentiality, and favouring relatives. Nonetheless, unlike previously reported, many patients preferred ART over alternative treatment (eg, traditional medicine) for its perceived efficacy, cost-free availability and accompanying clinical monitoring. CONCLUSION Findings demonstrate the dynamic effect of health system 'hardware' and 'software' factors on decisions to disengage. Our findings suggest a need for improved: physical resourcing and structuring of HIV services, preservice and inservice HCWs and management training and mentorship programmes to encourage HCWs to provide 'patient-centered' care and exercise 'flexibility' to meet patients' varying needs and circumstances.
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Affiliation(s)
- Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura Beres
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elvin Geng
- School of Medicine, University of California, San Francisco, California, USA
| | - Charles B Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Stephanie M Topp
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
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Fox MP, Pascoe SJS, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster-randomised evaluation. Trop Med Int Health 2018; 23:1314-1325. [PMID: 30281882 DOI: 10.1111/tmi.13152] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND As loss from HIV care is an ongoing challenge globally, interventions are needed for patients who don't achieve or maintain ART stability. The 2015 South African National Adherence Guidelines (AGL) for Chronic Diseases include two interventions targeted at unstable patients: early tracing of patients who miss visits (TRIC) and enhanced adherence counselling (EAC). METHODS As part of a cluster-randomised evaluation at 12 intervention and 12 control clinics in four provinces, intervention sites implemented the AGL interventions, while control sites retained standard care. We report on outcomes of EAC for patients with an elevated viral load (>400 copies/ml) and for TRIC patients who missed a visit by >5 days. We estimated risk differences (RD) of 3 and 12-month viral resuppression (<400 copies/ml) and 12-month retention with cluster adjustment using generalised estimating equations and controlled for imbalances using difference-in-differences compared to all eligible in 2015, prior to intervention roll-out. RESULTS For EAC, we had 358 intervention and 505 control site patients (61% female, median ART initiation CD4 count 154 cells/μl). We found no difference between arms in 3-month resuppression (RD: -1.7%; 95%CI: -4.3% to 0.9%), but <20% of patients had a repeat viral load within 3 months (19.8% intervention, 13.5% control). Including the entire clinic population eligible for EAC with a repeat viral load at all evaluation sites (n = 934), intervention sites showed a small increase in 3-month resuppression (28% vs. 25%, RD 3.0%; 95%CI: -2.7% to 8.8%). Adjusting for baseline differences increased the RD to 8.1% (95% CI: -0.1% to 17.2%). However, we found no differences in 12-month suppression (RD: 1.5%; 95% CI: -14.1% to 17.1% but suppression was low overall at 40%) or retention (RD: 2.8%; 95% CI: -7.5% to 13.2%). For TRIC, we enrolled 155 at intervention sites and 248 at control sites (44% >40 years, 67% female, median CD4 count 212 cells/μl). We found no difference between groups in return to care by 12 months (RD: -6.8%; 95% CI: -17.7% to 4.8%). During the study period, control sites continued to use tracing within standard care, however, potentially masking intervention effects. CONCLUSIONS Enhanced adherence counselling showed no benefit over 12 months. Implementation of the tracing intervention under the new guidelines was similar to the standard of care. Interventions that aim to return unstable patients to care should incorporate active monitoring to determine if the interventions are effective.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sophie J S Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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Hendrickson CJ, Pascoe SJS, Huber AN, Moolla A, Maskew M, Long LC, Fox MP. "My future is bright…I won't die with the cause of AIDS": ten-year patient ART outcomes and experiences in South Africa. J Int AIDS Soc 2018; 21:e25184. [PMID: 30318848 PMCID: PMC6186968 DOI: 10.1002/jia2.25184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 08/13/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION South Africa is moving into a new era of HIV treatment with "treat all" policies where people may be on treatment for most of their lives. We need to understand treatment outcomes and facilitators of long-term antiretroviral treatment (ART) adherence and retention-in-care in the South African context. In one of the first studies to investigate long-term treatment outcomes in South Africa, we aimed to describe ten-year patient outcomes at a large public-sector HIV clinic in Johannesburg and explore patient experiences of the treatment programme over this time in order to ascertain factors that may aid or hinder long-term adherence and retention. METHODS We conducted a cohort analysis (n = 6644) and in-depth interviews (n = 24) among HIV-positive adults initiating first-line ART between April 2004 and March 2007. Using clinical records, we ascertained twelve-month and ten-year all-cause mortality and loss to follow-up (LTF). Cox proportional hazards regression was used to identify baseline predictors of attrition (mortality and LTF (>3 months late for the last scheduled visit)) at twelve months and ten years. Twenty-four patients were purposively selected and interviewed to explore treatment programme experiences over ten years on ART. RESULTS Excluding transfers, 79.5% (95% confidence intervals (CI): 78.5 to 80.5) of the cohort were alive, in care at twelve months dropping to 35.1% (95% CI: 33.7 to 36.4) at ten years. Over 44% of deaths occurred within 12 months. Ten-year all-cause mortality increased, while LTF decreased slightly, with age. Year and age at ART initiation, sex, nationality, baseline CD4 count, anaemia, body mass index and initiating regimen were predictors of ten-year attrition. Among patients interviewed, the pretreatment clinic environment, feelings of gratitude and good fortune, support networks, and self-efficacy were facilitators of care; side effects, travel and worsening clinical conditions were barriers. Participants were generally optimistic about their futures and were committed to continued care. CONCLUSIONS This study demonstrates the complexities of long-term chronic HIV treatment with declining all-cause mortality and increasing LTF over ten years. Barriers to long-term retention still present a significant challenge. As more people become eligible for ART in South Africa under "treatment for all," new healthcare delivery challenges will arise; interventions are needed to ensure long-term programme successes continue.
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Affiliation(s)
- Cheryl J Hendrickson
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sophie J S Pascoe
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Aneesa Moolla
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mhairi Maskew
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence C Long
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Matthew P Fox
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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Pell C, Vernooij E, Masilela N, Simelane N, Shabalala F, Reis R. False starts in 'test and start': a qualitative study of reasons for delayed antiretroviral therapy in Swaziland. Int Health 2018; 10:78-83. [PMID: 29342259 DOI: 10.1093/inthealth/ihx065] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/30/2017] [Indexed: 11/14/2022] Open
Abstract
Background Test and start, antiretroviral therapy (ART) for all HIV-positive individuals, is a WHO-recommended treatment guideline. In Swaziland, test and start has been evaluated through the MaxART implementation study. This article examines why, in MaxART, some newly diagnosed HIV-positive clients delayed initiating ART. Methods Thirteen HIV-positive clients who delayed ART for ≥90 d after testing were identified from the MaxART study database and interviewed. Interviews were audio recorded, transcribed and translated into English for qualitative content analysis. Results Respondents had often tested positive several times before initiating ART, with the initial diagnosis sometimes completely unexpected. Repeat testing-and delayed ART-was linked to a desire to come to terms with their diagnosis and prepare for a lifelong treatment course. Clients previously enrolled in pre-ART, particularly with high CD4 counts, had internalized past messages about ART as being non-essential and taking care of oneself through other means. Concerns about ART-related adverse events were weighed against these messages. Worries about inadvertent disclosure and its impact on social and economic relationships also discouraged initiation. Conclusion Although potentially reducing logistical barriers, expedited ART initiation does not necessarily accommodate some clients' need for time to come to terms with the diagnosis and the prospect of lifelong treatment.
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Affiliation(s)
- Christopher Pell
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Amsterdam Institute for Global Health and Development (AIGHD), AHTC, Tower C4, Paasheuvelweg 25, 1105 BP, Amsterdam, The Netherlands
| | - Eva Vernooij
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Theory and History of Psychology, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands
| | | | | | - Fortunate Shabalala
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Swaziland, Mbabane, Swaziland
| | - Ria Reis
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands.,Children's Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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Habiyambere V, Dongmo Nguimfack B, Vojnov L, Ford N, Stover J, Hasek L, Maggiore P, Low-Beer D, Pérez Gonzàlez M, Edgil D, Williams J, Kuritsky J, Hargreaves S, NeSmith T. Forecasting the global demand for HIV monitoring and diagnostic tests: A 2016-2021 analysis. PLoS One 2018; 13:e0201341. [PMID: 30231022 PMCID: PMC6145505 DOI: 10.1371/journal.pone.0201341] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 07/13/2018] [Indexed: 12/31/2022] Open
Abstract
Introduction Despite considerable progress, just over half of the 37 million people eligible to start antiretroviral therapy (ART) have accessed treatment and millions of HIV-positive people still do not know their status. With demand for ART continuing to grow, meeting the ambitious 90-90-90 HIV treatment targets will depend on improved access to high-quality diagnostics to both diagnose infection and monitor treatment adherence in low and middle-income countries (LMICs). Robust projections of future demand for CD4, viral load (VL), HIV early-infant-diagnosis (EID) tests and HIV rapid diagnostic tests (RDTs) are needed as scale-up continues. Methods We estimate the current coverage for HIV diagnostics and project future demand to 2021 using a consolidated forecast using data on past coverage and current demand from a number of sources, from 130 predominantly LMIC countries. Results We forecast that the overall number of CD4 tests is expected to decline between now and 2021 as more countries adopt test-and-treat and shift to VL testing for patient monitoring. Our consolidated forecast projects a gradual decline in demand for CD4 tests to 16.6 million by 2021. We anticipate that demand for VL tests will increase to 28.5 million by 2021, reflecting the increasing number of people who will receive ART and the adoption of VL testing for patient monitoring. We expect that the demand for EID tests will grow more rapidly than in past years, driven by the implementation of testing at birth in programmes globally, in line with WHO guideline recommendations, doubling to 2.1 million tests by 2021. Demand for rapid diagnostic tests is also likely to increase, reaching 509 million tests by 2021. Discussion In order to achieve the ambitious 90-90-90 targets, it will be essential to maintain and improve access to CD4, VL, EID tests and RDTs. These projections provide insight into the global demand we can expect to see for these HIV monitoring and diagnostic tests, both in relation to historical trends, and the 90-90-90 targets. Our projections will better enable producers to ensure adequate supply, and to support procurement organisations in planning future funding and purchase plans to meet the anticipated demand. The findings highlight the ongoing need for governments and international funding bodies to prioritise improving capacity and access to HIV diagnostic and monitoring technologies in line with demand.
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Affiliation(s)
| | | | - L. Vojnov
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - N. Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - J. Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - L. Hasek
- CHAI, Boston, Massachusetts, United States of America
| | - P. Maggiore
- CHAI, Boston, Massachusetts, United States of America
| | - D. Low-Beer
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | - D. Edgil
- USAID, Washington DC, United States of America
| | - J. Williams
- US CDC, Atlanta, Georgia, United States of America
| | - J. Kuritsky
- USAID, Washington DC, United States of America
| | - S. Hargreaves
- International Health Unit, Imperial College London, London, United Kingdom
| | - T. NeSmith
- US CDC, Atlanta, Georgia, United States of America
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ART initiation in an outpatient treatment center in Dakar, Senegal: A retrospective cohort analysis (1998-2015). PLoS One 2018; 13:e0202984. [PMID: 30231075 PMCID: PMC6145516 DOI: 10.1371/journal.pone.0202984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/12/2018] [Indexed: 11/27/2022] Open
Abstract
Objective To examine how patient characteristics combined with ART eligibility expansions affect the initiation of antiretroviral therapy (ART) among eligible patients attending a referral center in Senegal from 1998 to 2015. Methods This is a retrospective observational study carried out at the outpatient treatment Centre (Centre de Traitement Ambulatoire) in Dakar, Senegal, based on computerized medical records, gathered from 1998 to 2015, of ART-naïve patients over 15 years of age. ART eligibility was defined as (CD4 count below 200) or as (WHO stage 4) or as (WHO stage 3 with (CD4 count below 350 or with unavailable CD4 count)) in 1998–2010; as (CD4 count below 350) or as (WHO stage 3 or 4) in 2011–2013; as (CD4 count below 500) or as (WHO stage 3 or 4) in 2014–2015. Four periods were defined according to ART eligibility expansions and Senegal’s HIV care history: 1998–2003 (P 1), 2004–2010 (P 2), 2011–2013 (P3), and 2014–2015 (P4). Patients were expected to participate financially in their treatment during the first period (P1). Results A total of 3651 patient records were included. The median patient age was 40 years (IQR: 32–48). Women represented 56% of the population. The median CD4 count was 183 cells/mm3. Overall, 53% of patients had CD4 < 200 cells/mm3 at entry. This proportion reached 45% in 2014–2015. 2535 patients (69%) were eligible for therapy, including 1503 (41%) who started ART. The proportion of treated patients among those who were eligible at entry or later increased steadily from 25%, 47%, 75% to 82% in the four periods, respectively. The median time to treatment decreased from 5.6 months (IQR: 3–11) in P1 to 0.8 months (IQR: 0–2) in P4. Eligible patients with more advanced disease (CD4<200 cells/mm3 and/or clinical stage 3 or 4) were more likely to be ART initiated than those with CD4≥200 cells/mm3 and/or clinical stage 1 or 2 at each stage of ART eligibility expansion. Conclusion ART eligibility expansions were marked by a sharp increase in the proportion of eligible patients initiating treatment. These results show that in terms of management, the target of "Test and Treat" can be easily reached but that HIV testing will remain a key element to improve treatment success, as illustrated by the high proportion of people with advanced stage of infection at the time of ART initiation.
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Guiteau Moise C, Rivera VR, Hennessey KA, Bellot C, Nicholas C, Fang AP, Verdier RI, Severe P, Sainvil A, Charles B, Dorval D, St Amour J, Pape JW, Koenig SP. A Successful Model of Expedited Antiretroviral Therapy for Clinically Stable Patients Living With HIV in Haiti. J Acquir Immune Defic Syndr 2018; 79:70-76. [PMID: 29771791 PMCID: PMC6092230 DOI: 10.1097/qai.0000000000001725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recommendations for universal antiretroviral therapy have greatly increased the number of HIV-infected patients who qualify for treatment, particularly with early clinical disease. Less intensive models of care are needed for clinically stable patients. SETTING A rapid pathway (RP) model of expedited outpatient care for clinically stable patients was implemented at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) Center, Port-au-Prince, Haiti. Expedited visits included nurse-led assessments and point-of-service antiretroviral therapy dispensing. METHODS We conducted a retrospective analysis including patients who initiated RP care between June 1, 2014, and September 30, 2015, comparing outcomes of patients with timely visit attendance (never >3 days late) with patients with ≥1 nontimely visit within 6 months before RP enrollment. We calculated retention in care and adherence at 12 months, and assessed predictors of both outcomes. RESULTS Of the 2361 patients who initiated RP care during the study period, 1429 (61%) had timely visit attendance and 932 (39%) had ≥1 nontimely visit before RP enrollment. Among RP-enrolled patients, 94% were retained at 12 months and 75% had ≥90% adherence, with higher proportions in those with timely pre-RP visits (95% vs. 92%; 87% vs. 55%). In multivariable analysis, pre-RP visit timeliness was associated with both retention (adjusted odds ratio: 1.67; 95% confidence interval: 1.08 to 2.59) and adherence (adjusted odds ratio: 4.53; 95% confidence interval: 3.58 to 5.72). CONCLUSIONS RP care was associated with high levels of retention and adherence for clinically stable patients. Timeliness of pre-RP visits was predictive of outcomes after RP initiation.
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Affiliation(s)
- Colette Guiteau Moise
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health, Weill Cornell Medical College, New York, NY
| | - Kelly A Hennessey
- Analysis Group, Boston, MA
- University of Washington School of Medicine, Seattle, WA
| | - Clovy Bellot
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Chris Nicholas
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Anna P Fang
- Analysis Group, Boston, MA
- Harvard Medical School, Boston, MA
| | - Rose Irène Verdier
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alix Sainvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Benedict Charles
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Derothy Dorval
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Juseline St Amour
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health, Weill Cornell Medical College, New York, NY
| | - Serena P Koenig
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA
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Ahmed S, Autrey J, Katz IT, Fox MP, Rosen S, Onoya D, Bärnighausen T, Mayer KH, Bor J. Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries. Soc Sci Med 2018; 213:72-84. [PMID: 30059900 PMCID: PMC6813776 DOI: 10.1016/j.socscimed.2018.05.048] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/15/2018] [Accepted: 05/25/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many people living with HIV (PLWH) who are eligible for antiretroviral therapy (ART) do not initiate treatment, leading to excess morbidity, mortality, and viral transmission. As countries move to treat all PLWH at diagnosis, it is critical to understand reasons for non-initiation. METHODS We conducted a systematic review of the qualitative literature on reasons for ART non-initiation in low- and middle-income countries. We screened 1376 titles, 680 abstracts, and 154 full-text reports of English-language qualitative studies published January 2000-April 2017; 20 met criteria for inclusion. Our analysis involved three steps. First, we used a "thematic synthesis" approach, identifying supply-side (facility) and demand-side (patient) factors commonly cited across different studies and organizing these factors into themes. Second, we conducted a theoretical mapping exercise, developing an explanatory model for patients' decision-making process to start (or not to start) ART, based on inductive analysis of evidence reviewed. Third, we used this explanatory model to identify opportunities to intervene to increase ART uptake. RESULTS Demand-side factors implicated in decisions not to start ART included feeling healthy, low social support, gender norms, HIV stigma, and difficulties translating intentions into actions. Supply-side factors included high care-seeking costs, concerns about confidentiality, low-quality health services, recommended lifestyle changes, and incomplete knowledge of treatment benefits. Developing an explanatory model, which we labeled the Transdisciplinary Model of Health Decision-Making, we posited that contextual factors determine the costs and benefits of ART; patients perceive this context (through cognitive and emotional appraisals) and form an intention whether or not to start; and these intentions may (or may not) be translated into actions. Interventions can target each of these three stages. CONCLUSIONS Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.
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Affiliation(s)
- Shahira Ahmed
- Department of Global Health, Boston University School of Public Health, Boston, United States
| | - Jessica Autrey
- Department of Global Health, Boston University School of Public Health, Boston, United States
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Massachusetts General Hospital, Center for Global Health, Boston, MA, United States
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, United States; Department of Epidemiology, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Till Bärnighausen
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kenneth H Mayer
- Harvard Medical School, Boston, MA, United States; The Fenway Institute, Boston, United States
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, United States; Department of Epidemiology, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa; Africa Health Research Institute, KwaZulu-Natal, South Africa.
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McNairy ML, Jannat-Khah D, Pape JW, Marcelin A, Joseph P, Mathon JE, Koenig S, Wells M, Fitzgerald DW, Evans A. Predicting death and lost to follow-up among adults initiating antiretroviral therapy in resource-limited settings: Derivation and external validation of a risk score in Haiti. PLoS One 2018; 13:e0201945. [PMID: 30157197 PMCID: PMC6114504 DOI: 10.1371/journal.pone.0201945] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 06/19/2018] [Indexed: 12/23/2022] Open
Abstract
Background Over 18 million adults have initiated life-saving antiretroviral therapy (ART) in resource-poor settings; however, mortality and lost-to-follow-up rates continue to be high among patients in their first year after treatment start. Clinical decision tools are needed to identify patients at high risk for poor outcomes in order to provide individualized risk assessment and intervention. This study aimed to develop and externally validate risk prediction tools that estimate the probability of dying or of being lost to follow-up (LTF) during the year after starting ART. Methods We used a derivation cohort of 7,031 adults age 15–70 years initiating ART from 2007 to 2013 at 6 clinics in Haiti; 242 (3.5%) had documented death and 1,521 (21.6%) were LTF at 1 year after starting ART. The following routinely collected data were used as predictors in two logistic regression models (one to predict death and another to predict LTF): age, gender, weight, CD4 count, WHO Stage, and diagnosis of tuberculosis (TB). The validation cohort consisted of 1,835 adults initiating ART at a different HIV clinic in Haiti during 2012. We assessed model discrimination by measuring the C-statistic, and measured model calibration by how closely the predicted probabilities approximated actual probabilities of the two outcomes. We derived a nomogram and a point-based risk score from the predictive models. Findings The model predicting death within the year after starting ART had a C-statistic of 0.75 (95% CI 0.74 to 0.81). There was no evidence for significant overfitting and the predictions were well calibrated. The strongest predictors of 1-year mortality were male gender, low weight, low CD4 count, advanced WHO stage, and the absence of TB. In the validation cohort, the C-statistic was 0.69 (95% CI 0.59 to 0.77). A point-based risk score for death had a C-statistic 0.73 (95% CI 0.69 to 0.76) and categorizes patients as low risk (<2% risk of death), average risk (3–4%), and high-risk (8–10%) and very high-risk (14–19%) with likelihood ratios to be used in settings where the baseline risk is different from our study population. The model predicting LTF did not discriminate well (C-statistic 0.59). Conclusions A simple risk-score using routinely collected data can predict 1-year mortality after ART initiation for HIV-positive adults in Haiti. However, predicting lost to follow-up using routinely collected data was not as successful. The next step is to assess whether use of this risk score can identify patients who need tailored services to reduce mortality in resource-poor settings such as Haiti.
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Affiliation(s)
- Margaret L. McNairy
- Division of General Internal Medicine, Weill Cornell Medicine, New York, United States of America
- Center for Global Health, Weill Cornell Medicine, New York, United States of America
- * E-mail:
| | - Deanna Jannat-Khah
- Division of General Internal Medicine, Weill Cornell Medicine, New York, United States of America
| | - Jean W. Pape
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince Haiti
| | - Adias Marcelin
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince Haiti
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince Haiti
| | - Jean Edward Mathon
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince Haiti
| | - Serena Koenig
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, United States of America
| | - Martin Wells
- Department of Statistical Science, Cornell University, Ithaca, United States of America
| | - Daniel W. Fitzgerald
- Center for Global Health, Weill Cornell Medicine, New York, United States of America
| | - Arthur Evans
- Division of General Internal Medicine, Weill Cornell Medicine, New York, United States of America
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Kelly JD, Hickey MD, Schlough GW, Conteh S, Sesay M, Rutherford GW, Giordano TP, Weiser SD. Understanding why HIV-infected persons disengaged from pre-ART care in Freetown, Sierra Leone: a qualitative study .. AIDS Care 2018; 31:494-497. [PMID: 30146898 DOI: 10.1080/09540121.2018.1515467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In countries that have not implemented universal antiretroviral treatment (ART), loss to follow-up (LTFU) during pre-ART care remains a problem. We conducted semi-structured interviews with 41 HIV-infected persons who were LTFU during pre-ART care from a prospective cohort of persons newly diagnosed with HIV infection in Freetown, Sierra Leone, in 2012-2013. Interviews determined whether the participant disengaged or transferred care and explored the reasons for being LTFU. Of the 41 participants, 34 (83%) disengaged from care. For persons who disengaged from care, socioeconomic barriers emerged as a dominant theme in both ART-eligible and -ineligible groups while psychosocial barriers emerged as a dominant theme in the ART-ineligible group. Structural barriers emerged as a dominant theme for participants who transferred care. Interventions designed to address socioeconomic and psychosocial barriers may help reduce disengagement from pre-ART care.
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Affiliation(s)
- J Daniel Kelly
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA.,b Wellbody Alliance , Koidu Town , Sierra Leone.,c National HIV/AIDS Secretariat , Freetown , Sierra Leone
| | - Matthew D Hickey
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
| | | | - Sulaiman Conteh
- c National HIV/AIDS Secretariat , Freetown , Sierra Leone.,d College of Medicine and Allied Health Sciences of University of Sierra Leone , Freetown , Sierra Leone
| | - Momodu Sesay
- c National HIV/AIDS Secretariat , Freetown , Sierra Leone
| | - George W Rutherford
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
| | - Thomas P Giordano
- e Department of Medicine , Baylor College of Medicine , Houston , TX , USA
| | - Sheri D Weiser
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
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Abstract
The benefits of combination antiretroviral therapy (cART) for HIV replication and transmission control have led to its universal recommendation. Many people living with HIV are, however, still undiagnosed or diagnosed late, especially in sub-Saharan Africa, where the HIV disease burden is highest. Further expansion in HIV treatment options, incorporating women-centred approaches, is essential to make individualised care a reality. With a longer life expectancy than before, people living with HIV are at an increased risk of developing non-AIDS comorbidities, such as cardiovascular diseases and cancers. Antiretroviral strategies are evolving towards a decrease in drug burden, and some two-drug combinations have proven efficacy for maintenance therapy. Investigational immune checkpoint inhibitors and broadly neutralising antibodies with effector functions have energised the HIV cure research field as the search for an effective vaccine continues. In this Seminar, we review advances and challenges relating to the goal of an AIDS-free world.
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Affiliation(s)
- Jade Ghosn
- Inserm UMR-S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Babafemi Taiwo
- Division of Infectious Diseases and Center for Global Health, Northwestern University, Chicago, Illinois, USA
| | - Soraya Seedat
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brigitte Autran
- Inserm UMR-S 1135, Centre de Recherches en Immunologie et Maladies Infectieus, CIMI-Paris, Université Pierre et Marie Curie, Paris, France
| | - Christine Katlama
- Inserm UMR-S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France; Paris-Sorbonne University, Paris, France; Assistance Publique-Hôpitaux de Paris, Department of Infectious Diseases, Hôpital Pitié Salpêtrière, Paris, France.
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Kohatsu L, Bolu O, Schmitz ME, Chang K, Lemwayi R, Arnett N, Mwasekaga M, Nkengasong J, Mosha F, Westerman LE. Evaluation of Specimen Types for Pima CD4 Point-of-Care Testing: Advantages of Fingerstick Blood Collection into an EDTA Microtube. PLoS One 2018; 13:e0202018. [PMID: 30138398 PMCID: PMC6107158 DOI: 10.1371/journal.pone.0202018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/26/2018] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Effective point-of-care testing (POCT) is reliant on optimal specimen collection, quality assured testing, and expedited return of results. Many of the POCT are designed to be used with fingerstick capillary blood to simplify the blood collection burden. However, fingerstick blood collection has inherent errors in sampling. An evaluation of the use of capillary and venous blood with CD4 POCT was conducted. METHODS Three different specimen collection methods were evaluated for compatibility using the Alere Pima CD4 assay at 5 HIV/AIDS healthcare sites in Dar es Salaam, Tanzania. At each site, whole blood specimens were collected from enrolled patients by venipuncture and fingerstick. Pima CD4 testing was performed at site of collection on venipuncture specimens (Venous) and fingerstick blood directly applied to a Pima CD4 cartridge (Capillary-Direct) and collected into an EDTA microtube (Capillary-Microtube). Venous blood was also tested at the laboratory by the reference CD4 method and Pima for comparison analysis. RESULTS All three specimen collection methods were successfully collected by healthcare workers for use with the Pima CD4 assay. When compared to the reference CD4 method, Pima CD4 testing with the Capillary-Microtube method performed similarly to Venous, while Pima CD4 counts with the Capillary-Direct method were slightly more biased (-20 cells/μL) and variable (-229 to +189 cells/μL limit of agreement). Even though all three collection methods had similar invalid Pima testing rates (10.5%, 9.8%, and 8.3% for Capillary-Direct, Capillary-Microtube, and Venous respectively), the ability to perform repeat testing with Capillary-Microtube and Venous specimens increased the likelihood of acquiring a valid CD4 result with the Pima assay. CONCLUSIONS Capillary blood, either directly applied to Pima CD4 cartridges or collected in an EDTA microtube, and venous blood are suitable specimens for Pima CD4 testing. The advantages of capillary blood collection in an EDTA microtube are that it uses fingerstick collection which mimics venous blood and allows extra testing without additional blood collection.
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Affiliation(s)
- Luciana Kohatsu
- United States Centers for Disease Control & Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Omotayo Bolu
- United States Centers for Disease Control & Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Mary E. Schmitz
- United States Centers for Disease Control & Prevention, Dar es Salaam, Tanzania
- Allan Rosenfield Global Health Fellowship, Association of Schools and Programs of Public Health, Washington DC, United States of America
| | - Karen Chang
- United States Centers for Disease Control & Prevention, Dar es Salaam, Tanzania
- Allan Rosenfield Global Health Fellowship, Association of Schools and Programs of Public Health, Washington DC, United States of America
| | - Ruth Lemwayi
- African Field Epidemiology Network, Dar es Salaam, Tanzania
| | - Nichole Arnett
- United States Centers for Disease Control & Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Michael Mwasekaga
- United States Centers for Disease Control & Prevention, Dar es Salaam, Tanzania
| | - John Nkengasong
- United States Centers for Disease Control & Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
| | - Fausta Mosha
- African Field Epidemiology Network, Dar es Salaam, Tanzania
- Ministry of Health Community Development Gender Elderly and Children, Government of Tanzania, Dar es Salaam, Tanzania
| | - Larry E. Westerman
- United States Centers for Disease Control & Prevention, Center for Global Health, Division of Global HIV/AIDS, Atlanta, Georgia, United States of America
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Jain K, Mshweshwe-Pakela NT, Charalambous S, Mabuto T, Hoffmann CJ. Enhancing value and lowering costs of care: a qualitative exploration of a randomized linkage to care intervention in South Africa. AIDS Care 2018; 31:481-488. [PMID: 30078352 DOI: 10.1080/09540121.2018.1503636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
While interventions to improve HIV linkage and retention in care exist, none have demonstrated results sufficient to reach UNAIDS 90-90-90 goals. We explored values and costs of seeking clinical care through testing three strategies to improve linkage to care: Point of care CD4 testing alone (POC-CD4), POC-CD4 combined with transportation support and combined with care facilitation. We conducted in-depth interviews with participants and transcribed audio-recordings of care facilitation sessions. Participants described values and costs enhanced or addressed by the three interventions. Psychosocial support provided through the care facilitation intervention appeared salient. Participants named other values and costs of seeking care unrelated to the intervention, such as encouragement from healthcare workers and aversion to lifelong treatment. Combined with the quantitative results of this trial, these findings may point to why the care facilitation arm was successful but not the POC-CD4 only or transportation arms. It also provides guidance for future interventions.
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Affiliation(s)
- Kriti Jain
- a Department of Health, Behavior, and Society , Johns Hopkins University Bloomberg School of Public Health , Baltimore , MD , USA
| | | | - Salome Charalambous
- b The Aurum Institute , Johannesburg , South Africa.,c The University of the Witwatersrand School of Public Health , Johannesburg , South Africa
| | - Tonderai Mabuto
- b The Aurum Institute , Johannesburg , South Africa.,c The University of the Witwatersrand School of Public Health , Johannesburg , South Africa
| | - Christopher J Hoffmann
- a Department of Health, Behavior, and Society , Johns Hopkins University Bloomberg School of Public Health , Baltimore , MD , USA.,b The Aurum Institute , Johannesburg , South Africa.,d Department of Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
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143
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Temporal Improvements in Long-term Outcome in Care Among HIV-infected Children Enrolled in Public Antiretroviral Treatment Care: An Analysis of Outcomes From 2004 to 2012 in Zimbabwe. Pediatr Infect Dis J 2018; 37:794-800. [PMID: 29356763 DOI: 10.1097/inf.0000000000001903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Increasing numbers of children are requiring long-term HIV care and antiretroviral treatment (ART) in public ART programs in Africa, but temporal trends and long-term outcomes in care remain poorly understood. METHODS We analyzed outcomes in a longitudinal cohort of infants (<2 years of age) and children (2-10 years of age) enrolling in a public tertiary ART center in Zimbabwe over an 8-year period (2004-2012). RESULTS The clinic enrolled 1644 infants and children; the median age at enrollment was 39 months (interquartile range: 14-79), with a median CD4% of 17.0 (interquartile range: 11-24) in infants and 15.0 (9%-23%) in children (P = 0.0007). Among those linked to care, 33.5% dropped out of care within the first 3 months of enrollment. After implementation of revised guidelines in 2009, decentralization of care and increased access to prevention of mother to child transmission services, we observed an increase in infants (48.9%-68.3%; P < 0.0001) and children (48.9%-68.3%; P < 0.0001) remaining in care for more than 3 months. Children enrolled from 2009 were younger, had lower World Health Organization clinical stage, improved baseline CD4 counts than those who enrolled in 2004-2008. Long-term retention in care also improved with decreasing risk of loss from care at 36 months for infants enrolled from 2009 (aHR: 0.57; 95% confidence interval: 0.34-0.95; P = 0.031). ART eligibility at enrollment was a significant predictor of long-term retention in care, while delayed ART initiation after 5 years of age resulted in failure to fully reconstitute CD4 counts to age-appropriate levels despite prolonged ART. CONCLUSIONS Significant improvements have been made in engaging and retaining children in care in public ART programs in Zimbabwe. Guideline and policy changes that increase access and eligibility will likely to continue to support improvement in pediatric HIV outcomes.
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144
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HIV transmission in discordant couples in Africa in the context of antiretroviral therapy availability. AIDS 2018; 32:1613-1623. [PMID: 29762171 DOI: 10.1097/qad.0000000000001871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The study aims to understand the basis of continued HIV-1 transmission in Zambian and Rwandan HIV-1-discordant couples in the context of antiretroviral therapy (ART). DESIGN We identified nine Zambian and seven Rwandan acutely infected, epidemiologically-linked couples from government couples' voluntary counseling and testing (CVCT) clinics where transmitting partners reported being on ART near the time of transmission. METHODS We quantified viral load and plasma antiretroviral drug concentrations near the time of transmission and used these as surrogate measures for adherence. We also sequenced the polymerase gene from both donor and recipient partners to determine the presence of drug resistance mutations (DRMs). RESULTS In Zambia, all transmitting partners had detectable viral loads, and 8/9 were not on therapeutic antiretroviral regimens. In the remaining couple, despite being on a therapeutic regimen, DRMs were present and transmitted. In Rwanda, although six of seven transmitting partners had detectable viral loads, therapeutic levels of antiretroviral drugs were detected in four of seven, but were accompanied by DRMs. In the remaining three couples, either no antiretrovirals or subtherapeutic regimens were detected. CONCLUSIONS A reduction of ART effectiveness in nontrial settings was associated with lack of antiretrovirals in plasma and detectable viral load, and also drug resistance. In Zambia, where CVCT is not widely implemented, inconsistent adherence was high in couples unaware of their HIV discordance. In Rwanda, where CVCT is deployed country-wide, virologic failure was associated with drug resistance and subsequent transmission. Together, these findings suggest that increasing ART availability in resource-limited settings without risk reduction strategies that promote adherence may not be sufficient to control the HIV epidemic in the post-ART era.
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145
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Tanser F, Vandormael A, Cuadros D, Phillips AN, de Oliveira T, Tomita A, Bärnighausen T, Pillay D. Effect of population viral load on prospective HIV incidence in a hyperendemic rural African community. Sci Transl Med 2018; 9:9/420/eaam8012. [PMID: 29237762 DOI: 10.1126/scitranslmed.aam8012] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/14/2017] [Accepted: 08/21/2017] [Indexed: 01/11/2023]
Abstract
Monitoring HIV population viral load (PVL) has been advocated as an important means of inferring HIV transmission potential and predicting the future rate of new HIV infections (HIV incidence) in a particular community. However, the relationship between PVL measures and directly measured HIV incidence has not been quantified in any setting and, most importantly, in a hyperendemic sub-Saharan African setting. We assessed this relationship using one of Africa's largest population-based prospective population cohorts in rural KwaZulu-Natal, South Africa in which we followed 8732 HIV-uninfected participants between 2011 and 2015. Despite clear evidence of spatial clustering of high viral loads in some communities, our results demonstrate that PVL metrics derived from aggregation of viral load data only from the HIV-positive members of a particular community did not predict HIV incidence in this typical hyperendemic, rural African population. Only once we used modified PVL measures, which combined viral load information with the underlying spatial variation in the proportion of the population infected (HIV prevalence), did we find a consistently strong relationship with future risk of HIV acquisition. For example, every 1% increase in the overall proportion of a population having detectable virus (PDV P ) was independently associated with a 6.3% increase in an individual's risk of HIV acquisition (P = 0.001). In hyperendemic African populations, these modified PVL indices could play a key role in targeting and monitoring interventions in the most vulnerable communities where the future rate of new HIV infections is likely to be highest.
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Affiliation(s)
- Frank Tanser
- Africa Health Research Institute, Durban 4001, South Africa. .,School of Nursing and Public Health, University of KwaZulu-Natal, Durban 4001, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban 4001, South Africa.,Research Department of Infection and Population Health, University College London, London WC1E 6JB, UK
| | - Alain Vandormael
- Africa Health Research Institute, Durban 4001, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban 4001, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Diego Cuadros
- Department of Geography and Geographic Information Science, University of Cincinnati, Cincinnati, OH 45220, USA
| | - Andrew N Phillips
- Institute for Global Health, University College London, London WC1E 6JB, UK
| | - Tulio de Oliveira
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban 4001, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa.,School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Andrew Tomita
- Africa Health Research Institute, Durban 4001, South Africa.,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa.,Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, Durban 4001, South Africa.,Research Department of Infection and Population Health, University College London, London WC1E 6JB, UK.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02138, USA.,Heidelberg Institute for Public Health, University of Heidelberg, Heidelberg 69117, Germany
| | - Deenan Pillay
- Africa Health Research Institute, Durban 4001, South Africa.,Division of Infection and Immunity, University College London, London WC1E 6JB, UK
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Norberg A, Nelson J, Holly C, Jewell ST, Salmond S. Experiences of HIV-infected adults and healthcare providers with healthcare delivery practices influencing engagement in primary healthcare settings: a qualitative systematic review protocol. ACTA ACUST UNITED AC 2018; 15:2645-2650. [PMID: 29135747 DOI: 10.11124/jbisrir-2016-003278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this qualitative systematic review is to examine the experience and impact of health care delivery on health care engagement for adults infected with the human immunodeficiency virus receiving primary care. This review will identify and synthesize the best available evidence on health care structures, processes and practices that promote patient engagement in primary health care.The review question to be addressed is: What are the experiences of people living with human immunodeficiency virus (PLWH) and their health care providers with health care delivery processes and practices that impact engagement in primary health care settings (clinics, physician offices, and other community-based health care settings)? Specifically this review will compile evidence to illuminate health care system structures, provider practices, care delivery and programmatic processes that impact engagement in primary health care, as perceived by PLWH and their providers.
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Affiliation(s)
- Andrea Norberg
- 1School of Nursing, Rutgers, The State University of New Jersey, Newark, USA 2The François Xavier Bagnoud Center, Rutgers School of Nursing, Rutgers, Rutgers, The State University of New Jersey, Newark, USA 3The Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Centre of Excellence 4George F. Smith Library of the Health Sciences, Rutgers, The State University of New Jersey, Newark, USA
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Venter W, Coleman J, Chan VL, Shubber Z, Phatsoane M, Gorgens M, Stewart-Isherwood L, Carmona S, Fraser-Hurt N. Improving Linkage to HIV Care Through Mobile Phone Apps: Randomized Controlled Trial. JMIR Mhealth Uhealth 2018; 6:e155. [PMID: 30021706 PMCID: PMC6068383 DOI: 10.2196/mhealth.8376] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 03/21/2018] [Accepted: 04/08/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In HIV treatment program, gaps in the "cascade of care" where patients are lost between diagnosis, laboratory evaluation, treatment initiation, and retention in HIV care, is a well-described challenge. Growing access to internet-enabled mobile phones has led to an interest in using the technology to improve patient engagement with health care. OBJECTIVE The objectives of this trial were: (1) to assess whether a mobile phone-enabled app could provide HIV patients with laboratory test results, (2) to better understand the implementation of such an intervention, and (3) to determine app effectiveness in improving linkage to HIV care after diagnosis. METHODS We developed and tested an app through a randomized controlled trial carried out in several primary health care facilities in Johannesburg. Newly diagnosed HIV-positive patients were screened, recruited, and randomized into the trial as they were giving a blood sample for initial CD4 staging. Trial eligibility included ownership of a phone compatible with the app and access to the internet. Trial participants were followed for a minimum of eight months to determine linkage to HIV care indicated by an HIV-related laboratory test result. RESULTS The trial outcome results are being prepared for publication, but here we describe the significant operational and technological lessons provided by the implementation. Android was identified as the most suitable operating system for the app, due to Android functionality and communication characteristics. Android also had the most significant market share of all smartphone operating systems in South Africa. The app was successfully developed with laboratory results sent to personal smartphones. However, given the trial requirements and the app itself, only 10% of screened HIV patients successfully enrolled. We report on issues such as patient eligibility, app testing in a dynamic phone market, software installation and compatibility, safe identification of patients, linkage of laboratory results to patients lacking unique identifiers, and present lessons and potential solutions. CONCLUSIONS The implementation challenges and lessons of this trial may assist future similar mHealth interventions to avoid some of the pitfalls. Ensuring sufficient expertise and understanding of the programmatic needs by the software developer, as well as in the implementation team, with adequate and rapid piloting within the target groups, could have led to better trial recruitment. However, the majority of screened patients were interested in the study, and the app was installed successfully in patients with suitable smartphones, suggesting that this may be a way to engage patients with their health care data in future. TRIAL REGISTRATION ClinicalTrials.gov NCT02756949; https://clinicaltrials.gov/ct2/show/NCT02756949 (Archived by WebCite at http://www.webcitation.org/6z1GTJCNW).
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Affiliation(s)
- Willem Venter
- Wits Reproductive Health and HIV Institute, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jesse Coleman
- Wits Reproductive Health and HIV Institute, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Vincent Lau Chan
- Wits Reproductive Health and HIV Institute, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mothepane Phatsoane
- Wits Reproductive Health and HIV Institute, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Lynsey Stewart-Isherwood
- National Health Laboratory Services, Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sergio Carmona
- National Health Laboratory Services, Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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148
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Abstract
HIV behavioral research has provided an invaluable knowledge base for effective approaches to behavioral challenges along the HIV care cascade. Little attention has been paid to tracking unanticipated effects of research participation, whether negative or positive. We used qualitative methods to elicit impressions of unanticipated effects of participation in behavioral research. An instrument was developed and piloted to assess positive (emotional gains, practical gains, HIV prevention knowledge and skills gains) and negative (emotional stress, discomfort with research) unanticipated effects. Participants (N = 25) from five projects, including men who have sex with men, adults who use substances, and youth, reported multiple positive unanticipated effects (sexual and drug risk reduction, goal setting, improvements in self-esteem and mood, relationship gains, health care behavior gains, knowledge and introspection gains) and rare unanticipated negative effects. Developing a systematic tool of unanticipated positive and negative effects of participation in behavioral research is a crucial next step.
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149
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Camlin CS, Cassels S, Seeley J. Bringing population mobility into focus to achieve HIV prevention goals. J Int AIDS Soc 2018; 21 Suppl 4:e25136. [PMID: 30027588 PMCID: PMC6053544 DOI: 10.1002/jia2.25136] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive SciencesDepartment of MedicineUniversity of CaliforniaSan FranciscoUSA
| | - Susan Cassels
- Department of GeographyUniversity of CaliforniaSanta BarbaraUSA
| | - Janet Seeley
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
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Idindili BM, King SJ, Stolka K, Mashasi I, Bashosho P, Karungula H, Chintowa F, Mwakabole G, Ashburn K, Do B, Goco N. HIV care and treatment clinic performance following President’s Emergency Plan for AIDS Relief-funded infrastructure improvement in Tanzania. South Afr J HIV Med 2018. [DOI: 10.4102/sajhivmed.v19i1.777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Purpose: To assess how the infrastructure improvements supported by the US Centers for Disease Control and Prevention (CDC) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) contributed to facility-level quarterly and annual new patient enrolment in HIV care and treatment and antiretroviral therapy (ART) uptake and retention in care.Methods: Aggregate quarterly and annual facility-based HIV care and treatment data from the CDC-managed PEPFAR Reporting Online and Management Information System database collected between 2005 and 2012 were analysed for the 11 rural and 32 urban facilities that met the eligibility criteria. Infrastructure improvements, including both renovations and new construction, occurred on different dates for the facilities; therefore, data were adjusted such that pre- and post-infrastructure improvements were aligned and date-time was ignored. The analysis calculated the mean (95% confidence interval) number of patients per facility who were (1) newly enrolled in HIV care, (2) patients initiated on ART, (3) patients retained in care, defined as alive and on ART, and (4) reasons for attrition, defined as transferred out, lost to follow-up, deceased or stopped ART.Results: The overall mean number of adult patients newly enrolled in HIV care clinics per quarter declined from 187.7 (151.4–223.9) to 135.2 (117.4–152.9) after infrastructure improvements but was not statistically significant (p = 0.20). However, the mean number of patients who were alive and remained on ART increased from 193.2 (145.3–241.1) to 273.2 (219.0–327.3) after improvements in both rural and urban facilities, although not significantly (p = 0.59). A similar picture was observed for overall paediatric enrolment and retention in care. Health facility-specific case studies show variations in new patient enrolment and retention in care between health facilities depending on the catchment area, population HIV prevalence and coverage of ART facilities. Regarding attrition, the mean number of adult patients lost to follow-up changed from 76.6 (20.8–132.3) to 139.4 (79.6–199.1) (p = 0.65) among rural facilities, while the mean number of children lost to follow-up increased significantly from 3.4 (0.5–6.3) to 8.7 (5.0–12.3) (p = 0.02) after improvements.Conclusion: Patient retention in care improved in HIV care and treatment facilities with infrastructure improvements. However, the overall number of patients newly enrolled and initiated on ART declined and attrition increased in facilities after improvements.
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